Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy

Impact of Positive Surgical Margins After Partial Nephrectomy

Background

The impact of positive surgical margins (PSMs) after partial nephrectomy (PN) is controversial.

Objective

To evaluate the risk factors for a PSM and its impact on overall survival.

Design, setting, and participants

This is a retrospective study of 388 patients were submitted to PN between November 2005 and December 2016 in a single centre. Two groups were created: PSM and negative surgical margin (NSM) after PN. A p value of <0.05 was considered significant.

Outcome measurements and statistical analysis

Relationships with outcome were assessed using univariable and multivariable tests and log-rank analysis.

Results and limitations

The PSM rate was 3.8% (N = 16). The mean age at the time of surgery (PSM group: 64.1 ± 11.3 vs NSM group: 61.8 ± 12.8 yr, p =  0.5) and the mean radiological tumour size (4.0 ± 1.5 vs 3.4 ± 1.8 cm, p =  0.2) were similar. Lesion location (p =  0.3), surgical approach (p =  0.4), warm ischaemia time (p =  0.9), and surgery time (p =  0.06) had no association with PSM. However, higher surgeon experience was associated with a lower PSM incidence (2.6% if ≥30 PNs vs 9.6% if <30 PNs; p =  0.02). Higher operative blood loss (p =  0.02), higher-risk tumours (p =  0.03), and larger pathological size (p =  0.05) were associated with an increase in PSM. In the PSM group, recurrence rate (18.7% vs 4.2%, p =  0.007) and secondary total nephrectomy rate (25% vs 4.4%, p <  0.001) were higher. However, overall survival was similar. Multivariate analysis revealed that high-risk tumour (p =  0.05) and low experience (p =  0.03) could predict a PSM. Limitations include retrospective design and reduced follow-up time.

Conclusions

PSMs were mainly associated with high-risk pathological tumour (p =  0.05) and low-volume surgeon experience. Recurrence rate and need for total nephrectomy were higher in that group, but no impact on survival was noticed.

Patient summary

The impact of positive surgical margins (PSMs) after partial nephrectomy is a matter of debate. In this study, we found that PSMs were mainly associated with aggressive disease and low surgeon experience.

Achieving the "trifecta" with open versus minimally invasive partial nephrectomy

INTRODUCTION

The "trifecta" is a summary measure of outcome after partial nephrectomy (PN) that encompasses three parameters: negative surgical margin, ≤ 10% decrease in post-operative estimated glomerular filtration rate (eGFR) and absence of urological complications. We assessed trifecta rates in patients undergoing open (OPN), laparoscopic (LPN), and robotic PN (RPN) for a clinical T1 renal mass (≤ 7 cm).

METHODS

Clinical and pathologic parameters were extracted from the prospectively maintained Canadian Kidney Cancer Information System for patients treated between January 2011 and October 2018. Comparisons between groups were made using Kruskal-Wallis test for continuous variables and Chi-squared independence test for categorical variables. Multivariable analysis was performed to identify predictors of each component of the trifecta and the trifecta itself.

RESULTS

Of 1708 total patients, 746 underwent OPN, 678 LPN, and 284 RPN for a T1 renal mass. A 'trifecta' was achieved in 53% OPN, 52% LPN and 47% RPN (p = 0.194). On multivariable analysis, OPN and LPN were associated with less frequent post-operative decline in eGFR and more frequent trifecta when compared to RPN, but there was no difference between OPN and LPN. OPN also predicted a higher rate of negative margins compared to RPN but not LPN.

CONCLUSION

After correction for confounding variables, OPN and LPN were more likely than RPN to achieve the trifecta, which appeared to be due primarily to loss of renal function. No difference was observed between OPN and LPN. Analyses were limited by the lack of nephrometry score.

Small renal masses in Latin-American population: characteristics and prognostic factors for survival, recurrence and metastasis - a multi-institutional study from LARCG database

Background

To evaluate demographic, clinical and pathological characteristics of small renal masses (SRM) (≤ 4 cm) in a Latin-American population provided by LARCG (Latin-American Renal Cancer Group) and analyze predictors of survival, recurrence and metastasis.

Methods

A multi-institutional retrospective cohort study of 1523 patients submitted to surgical treatment for non-metastatic SRM from 1979 to 2016. Comparisons between radical (RN) or partial nephrectomy (PN) and young or elderly patients were performed. Kaplan-Meier curves and log-rank tests estimated 10-year overall survival. Predictors of local recurrence or metastasis were analyzed by a multivariable logistic regression model.

Results

PN and RN were performed in 897 (66%) and 461 (34%) patients. A proportional increase of PN cases from 48.5% (1979–2009) to 75% (after 2009) was evidenced. Stratifying by age, elderly patients (≥ 65 years) had better 10-year OS rates when submitted to PN (83.5%), than RN (54.5%), p = 0.044. This disparity was not evidenced in younger patients. On multivariable model, bilaterality, extracapsular extension and ASA (American Society of Anesthesiologists) classification ≥3 were predictors of local recurrence. We did not identify significant predictors for distant metastasis in our series.

Conclusions

PN is performed in Latin-America in a similar proportion to developed areas and it has been increasing in the last years. Even in elderly individuals, if good functional status, sufficiently fit to surgery, and favorable tumor characteristics, they should be encouraged to perform PN. Intending to an earlier diagnosis of recurrence or distant metastasis, SRM cases with unfavorable characteristics should have a more rigorous follow-up routine.

Kidney ventrally rotation technique in retroperitoneal robot-assisted partial nephrectomy for posterior hilar tumor: technical feasibility and preliminary results

PURPOSE

The retroperitoneal robotic assisted partial nephrectomy (RAPN) is suitable for tumors locating on the posterior side of the kidney. However, the posterior hilar tumor poses an additional surgical challenge due to the special location and poor tumor exposure. We developed a novel kidney ventrally rotation technique to overcome this difficulty during retroperitoneal RAPN and evaluated its efficacy in a retrospective case-control comparative study.

METHODS

From March 2016 to April 2019, a total of 39 patients with posterior renal hilar tumor underwent retroperitoneal RAPN. The kidney ventrally rotation technique, which improved the tumor exposure by opening the peritoneum and rotating the kidney ventrally, was applied in 24 cases, and the conventional RAPN was performed in the other 15 cases (control group). Perioperative data was analyzed to evaluate the efficacy of the kidney ventrally rotation technique.

RESULTS

In kidney rotation group, the 24 patients underwent RAPN successfully without converting to open surgery or radical nephrectomy. The warm ischemia time was 17.4 ± 6.6 min, which was significantly shorter than 24.5 ± 8.3 min in control group. The mean operation time (80 ± 24 min) and estimated blood loss (104 ± 65 ml) were not different from the control group. No sever complications occurred, and no positive surgical margin was found in all the malignant cases. After 14 months follow-up, no recurrence or metastasis occurred in all cases.

CONCLUSION

Kidney ventrally rotation technique is safe and feasible for improving the exposure of posterior renal hilar tumor during retroperitoneal RAPN. It could be regarded as an efficient option for the management of posterior hilar tumor.

Impact of radiological morphology of clinical T1 renal cell carcinoma on the prediction of upstaging to pathological T3

OBJECTIVES

Previous studies have reported that cases with clinical T1 renal cell cancer upstaging to pathological T3 are a risk factor to predicting postoperative recurrence after partial nephrectomy. The aim of our study was to investigate the impact of the radiological morphology of the enhanced CT scan of clinical T1 renal cell cancer on predicting upstaging to pathological T3.

METHODS

Three hundred sixty-seven cases with clinical T1 renal cell cancer diagnosed from enhanced CT scans were enrolled in this study. Based on the findings from the enhanced CT scan, the cases were classified into 'round', the margins of which were smooth and round; 'lobular', one or more findings of smooth dent and no spiky dent were identified on the margin of the tumor; and 'irregular', one or more spiky dent were identified on the margin of the tumor. The association of postoperative upstaging with these radiological morphology and other clinical characteristics of each case was analyzed.

RESULTS

Eighteen cases (4.9%) pathologically upstaged to T3a. Two round case (0.7%), 3 lobular cases (10.0%) and 13 irregular cases (22.0%) pathologically upstaged (P < 0.001, round + lobular versus irregular). Four of 17 cases (23.5%) with hilar tumors pathologically upstaged, while 14 of 350 cases (4%) with tumors pathologically upstaged in other sites (P < 0.001). Multivariate analysis revealed that irregular case was an independent factor in predicting upstaging to pathological T3a (P < 0.001).

CONCLUSIONS

Evaluation of the radiological morphology of clinical T1 renal cell cancer based on enhanced CT scans is useful for predicting pathological upstaging.

Partial vs. radical nephrectomy and the risk of all-cause mortality, cardiovascular, and nephrological outcomes

INTRODUCTION

The study's objective was to examine the effects of renal-preservation surgery on long-term mortality, cardiovascular outcomes, and renal-related outcomes.

METHODS

We performed a retrospective cohort study of all partial (n=575) and radical nephrectomies (n=882) for tumors ≤7 cm in diameter between 2002 and 2010 across three academic centers in Ontario, Canada. We linked records from provincial databases to assess patient characteristics and outcomes (median seven years' followup using retrospective data). A weighted propensity score was used to reduce confounding. The primary outcome was all-cause mortality. Secondary outcomes included hospitalization with major cardiovascular events, non-cancer related mortality, kidney cancer-related mortality, and dialysis.

RESULTS

Mean one-year postoperative estimated glomerular filtration rate (eGFR) was 71 mL/min/1.73 m² in the partial group and 52 mL/min/1.73 m² in the radical group. Partial nephrectomy was associated with a lower risk of all-cause mortality in the first five years after surgery (hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.27-0.66), which did not extend beyond five years (HR 1.01, 95% CI 0.68-1.49). Kidney cancer-related mortality was lower in the partial compared to the radical group for the first four years after surgery (HR 0.16, 95% CI 0.04-0.72). There were no significant differences between the groups for cardiovascular outcomes or non-cancer related deaths.

CONCLUSIONS

Overall survival and cancer-specific survival was reduced in radical nephrectomy patients. However, despite reduced renal function in the radical nephrectomy group, non-cancer-related death, cardiovascular events, and dialysis were not significantly different between groups. Long-term benefits of partial nephrectomy may be less than previously believed.

Acute kidney injury after nephrectomy: a new nomogram to predict postoperative renal function

Background

We aimed to develop a nomogram based on preprocedural features for early prediction of acute kidney injury (AKI) and to assess the prognosis in patients after radical and partial nephrectomy.

Methods

The study included a development cohort of 1111 patients who were treated between June 2012 and June 2017 and an additional validation cohort of 356 patients who were treated between July 2017 and June 2018. Stepwise regression and logistic regression analyses were used to evaluate the association between predictors and AKI. Incorporating all independent predictors, a nomogram for postoperative AKI was developed and externally validated. Patients were followed up for 5 years to assess renal function, acute kidney disease (AKD), chronic kidney disease (CKD), hospital readmission and mortality were key prognosis we focused on.

Results

After multivariate logistic regression, radical nephrectomy (odds ratio (OR) = 3.57, p < 0.001), aspirin (OR = 1.79, p = 0.008), systolic blood pressure (OR = 1.41, p = 0.004), triglyceride (OR = 1.26, p = 0.024), and alkaline phosphatase (OR = 1.75, p = 0.034) were independent risk factors for postoperative AKI, while albumin (OR = 0.72, p = 0.031) was a protective factor for postoperative AKI. Patients with a higher estimated glomerular filtration rate (eGFR) (60–90 ml/min/1.73 m², OR = 0.41, p = 0.004; ≥ 90 ml/min/1.73 m², OR = 0.37, p < 0.001) were less prone to AKI than those with a lower eGFR (< 15 ml/min/1.73 m²). These predictors were all included in the final nomogram. The area under the receiver operating characteristics curve for the model were 0.77 (p < 0.001) in the development cohort and 0.72 (p < 0.001) in the validation cohort. The incidence of AKD and CKD were 27.12 and 18.64% in AKI group, which were much higher than those in no AKI group (p < 0.001).

Conclusions

The nomogram had excellent predictive ability and might have significant clinical implications for the early detection of AKI in patients undergoing nephrectomy.

Robotic and open partial nephrectomy for intermediate and high complexity tumors: a matched-pairs comparison of surgical outcomes at a single institution

Objective: To compare peri-operative factors and renal function following open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN) for intermediate and high complexity tumors when controlling for tumor and patient complexity.Methods: A retrospective review of 222 patients undergoing partial nephrectomy was performed. Patients with intermediate (nephrometry score NS 7-9) or high (NS 10-12) complexity tumors were matched 2:1 for RPN:OPN using NS, Charlson Comorbidity Index (CCI), and BMI. Patient demographics, peri-operative values, renal function, and complication rates were analyzed and compared.Results: Seventy-four OPN patients were matched to 148 RPN patients with no difference in patient demographics. Estimated blood loss in OPN patients was significantly higher (368.5 vs 210.5 mL, p < 0.001) as was transfusion rate (17% vs 1.6%, p < 0.001). Warm ischemia time was longer in OPN (25.5 vs 19.7 min, p = 0.001) while operative time was reduced (200.5 vs 226.5 min, p = 0.010). RPN patients had significantly shorter hospitalizations (5.3 vs 3.0 days, p < 0.001). GFR decrease after one month was not statistically significant (12.9 vs 6.6 ml/min, p = 0.130). Clavien III-V complications incidence was higher for OPN compared to RPN although not significantly (20.3% vs 10.8%, p = 0.055).Conclusion: When matching for tumor and patient complexity, RPN patients had fewer high grade post-operative complications, decreased blood loss, and shorter hospitalizations. RPN is a safe option for patients with intermediate and high complexity tumors.

Robotic-assisted surgery for the treatment of urologic cancers: recent advances

INTRODUCTION

As the medical field is moving toward personalized and tailored approaches, we entered the era of precision surgery for the management of genitourinary cancers1. This is facilitated by the implementation of new technologies, among which robotic surgery stands out for the significant impact in the surgical field over the last two decades.

AREAS COVERED

This article reviews the latest evidence on robotic surgery for the treatment of urologic cancers, including prostate, kidney, bladder, testis, and penile cancer. Functional and oncologic outcomes, new surgical techniques, new imaging modalities, and new robotic platforms are discussed.

EXPERT OPINION

Robotic surgery had a growing role in the management of genitourinary cancers over the past 10 years. Despite a lack of high-quality evidence comparing the effectiveness of robotic to open surgery, the robotic approach allowed a larger adoption of a minimally invasive surgical approach, translating into lower surgical morbidity and shorter hospital stay. New robotic platforms might allow to explore novel surgical approaches, and new technologies might facilitate surgical navigation and intraoperative identification of anatomical structures, allowing a more tailored and precise surgery. It is an exciting time for robotic surgery, and upcoming technological advances will offer better outcomes to urologic cancer patients.

Impact of radical nephrectomy on kidney function and prognostic factors for adverse cardiovascular events

INTRODUCTION AND OBJECTIVES

To analyze the evolution of kidney function after radical nephrectomy and to evaluate risk factors for adverse cardiovascular events during a long follow-up.

MATERIAL AND METHODS

Retrospective study of patients submitted to radical nephrectomy due to renal cancer from January of 1996 to January of 2016. We evaluated their renal function after nephrectomy and during follow-up. We analyzed the possible predictive factors for adverse cardiovascular events with univariate and multivariate logistic regression analyses.

RESULTS

There was an acute drop in glomerular filtration rate (GFR) after nephrectomy (21.2ml/min), which stabilized during follow-up in most cases. We evaluated the possible predictive factors for adverse cardiovascular events with logistic regression analyses, which presented previous cardiovascular disease (0,270, 95% CI 0,123-0,594, P<.001), diabetes (0,364, 95% CI 0,162-0,818 P=.015) and de novo hypertension (0,239, 95% CI 0,098-0,581, P=.002) as independently associated with the occurrence of adverse cardiovascular events.

CONCLUSION

There was a deleterious effect in renal function after nephrectomy which remained stable during subsequent years in most patients. Approximately half of our patients had a GFR lower than 60mL/min after nephrectomy. Previous cardiovascular disease, diabetes and de novo hypertension were shown as risk factors for adverse cardiovascular events.

Ten-Year Experience with Percutaneous Cryoablation of Renal Tumors: Tumor Size Predicts Disease Progression

Introduction: Percutaneous cryoablation (PCA) has emerged as an alternative to extirpative management of small renal masses (SRMs) in select patients, with a reduced risk of perioperative complications. Although disease recurrence is thought to occur in the early postoperative period, limited data on long-term oncologic outcomes have been published. We reviewed our 10-year experience with PCA for SRMs and assessed predictors of disease progression. Materials and Methods: We reviewed our prospectively maintained database of patients who underwent renal PCA from March 2005 to December 2015 (n = 308). Baseline patient and tumor variables were recorded, and postoperative cross-sectional imaging was examined for evidence of disease recurrence. Disease progression was defined as the presence of local recurrence or new lymphadenopathy/metastasis. Results: Mean patient age was 67.2 ± 11 years, mean tumor size was 2.7 ± 1.3 cm, and mean nephrometry score was 6.8 ± 1.7. At mean follow-up of 38 months, local recurrence and new lymphadenopathy/metastasis occurred in 10.1% (31/308) and 6.2% (19/308) of patients, respectively. Excluding patients with a solitary kidney and/or von Hippel-Lindau, local recurrence and new lymphadenopathy/metastasis occurred in 8.6% (23/268) and 1.9% (5/268) of cases, respectively. Kaplan-Meier estimated disease-free survival was 92.5% at 1 year, 89.3% at 2 years, and 86.7% at 3 years post-PCA. Increasing tumor size was a significant predictor of disease progression (hazard ratio 1.32 per 1-cm increase in size, p = 0.001). Conclusions: PCA is a viable treatment option for patients with SRMs. Increasing tumor size is a significant predictor of disease progression following PCA.

Nephron-Sparing Robotic Radiosurgical Therapy for Primary Renal Cell Carcinoma: Single-Institution Experience and Review of the Literature

PURPOSE

We report our single-institution stereotactic body radiation therapy (SBRT) experience on stage I renal cancer with prospectively collected toxicity and efficacy data.

METHODS AND MATERIALS

A total of 21 patients with solitary renal tumors, including 14 surgical candidates who refused surgery (66%), were treated with SBRT. Histologic confirmation was obtained on all patients before treatment; 2 had transitional cell carcinoma and 19 had renal cell carcinoma. The median age was 71 years (range, 58-88). Nearly all patients received 48 Gy in 3 fractions.

RESULTS

The median follow-up was 78 months (range, 5-107). At 5 years post treatment, the local tumor control rate was 100%. Tumor size decreased by a median value of 5.3% at 1 year post treatment, 15.6% at 2 years post treatment, and 15.4% at 5 years post treatment. Glomerular filtration rate had decreased by a median value of 1.5% at 1 year post treatment, 7.0% at 2 years post treatment, and 14.2% at 5 years post treatment. Three patients experienced grade 1 toxicity; no other treatment-related adverse effects were reported.

CONCLUSIONS

SBRT is a promising noninvasive treatment in the management of primary renal cell carcinoma, with evolving clinical evidence demonstrating encouraging results with respect to local control and toxicity.

A large bi-lobed classic renal angiomyolipoma with vena caval extension

Renal angiomyolipomas (AMLs) are the most common benign renal tumors encountered, and composed of 3 components: mature adipose tissues, smooth muscles, and blood vessels. Mostly asymptomatic and discovered incidentally, the classic type of AMLs rarely extend to involve great vessels. Radiological confirmation of such lesions is paramount for diagnosis and planned intervention. Management of AMLs is based on clinical presentation and varies from active surveillance to invasive surgical interventions. A case of sizeable classic AML with extension to inferior vena cava is presented here, with successful tumor resection performed after complete liver mobilization. A literature review and a summary of similar cases are also presented. A multidisciplinary approach is required for proper and precise radiological diagnosis to achieve an adequate surgical resection, which might sometimes be complicated and complex, as in this current case.

Absence of asymptomatic unruptured renal artery pseudoaneurysm on contrast-enhanced computed tomography after robot-assisted partial nephrectomy without parenchymal renorrhaphy

Objective

To assess the incidence of asymptomatic unruptured renal artery pseudoaneurysm (RAP) on contrast-enhanced computed tomography (CE-CT) after robot-assisted partial nephrectomy (RAPN) without parenchymal renorrhaphy.

Methods

From May 2016 to December 2017, 78 patients underwent RAPN for renal tumors. Inner suture was performed in the opened collecting system or renal sinus, whereas parenchymal renorrhaphy was not. For hemostasis, the soft coagulation system was used, and absorbable hemostats were placed on the resection bed. CE-CT was carried out within 7 days after surgery. Data on these patients were prospectively collected. A single radiologist determined the diagnosis of RAP.

Results

Median (range) data were as follows: Patient age, 65 (19–82) years; radiographic tumor size, 30 (12–95) mm; operating time, 166 (102–294) min; warm ischemic time, 16 (7–67) min; and blood loss, 15 (0–4450) mL. One patient (1.6%) required a perioperative blood transfusion. No patient required conversion to open surgery or nephrectomy. CE-CT was carried out at median 6 (3–7) days after surgery. CE-CT showed no RAP development in all 61 patients. Urinary leakage was not observed. One patient had acute cholecystitis, a postoperative complication classified as Clavien-Dindo grade higher than 3, which was treated with cholecystectomy. Positive surgical margin was identified in four patients (6.6%).

Conclusion

RAPN using soft coagulation and absorbable hemostats without renorrhaphy appears to be feasible and safe. Our technique could eliminate the risk of RAP.

Partial Nephrectomy in pT3a Tumors Less Than 7 cm in Diameter Has a Superior Overall Survival Compared to Radical Nephrectomy

Objectives We conducted this study to analyze the survival rates of patients with advanced renal tumors <7 cm in diameter treated surgically by partial nephrectomy (PN) compared to those who received radical nephrectomy (RN). Material and methods We retrospectively analyzed clinical data from 55 consecutive patients from our institutional database with T3a renal cell carcinoma of <7 cm treated surgically either by PN (n = 38) or RN (n = 17) in the Department of Urology of Ludwig Maximilians University from January 2006 to August 2014. The overall survival (OS) rates were calculated according to Kaplan-Meier estimation. Results The median age of the population was 67.9 years (range: 39.4 to 87.9 years). The median blood loss was 164.1 ml (range: 0 to 1200 ml), and the median clamping time was 8.85 minutes (range: 0 to 38 minutes). On average, the surgery lasted for 118 minutes (range: 40 to 210 minutes). The median serum creatinine level measured was 1.2 mg/dl (range: 0.7 to 2.3 mg/dl) preoperatively, and 1.4 mg/dl (range: 0.7 to 4.3 mg/dl) postoperatively. The median creatinine serum level measured during follow up was 1.4 ng/ml in individuals with a PN (range: 0.7 to 3.2 ng/ml), and 1.5 ng/ml in those with an RN (range: 0.9 to 4.3 ng/ml). Patients with an RN had a median OS of 38.6 months (range: 0 to 63.3 months). The median OS for patients with a PN was not reached after a follow-up of 80 months. The difference in OS in patients with PN and RN was statistically significant (P < 0.005). Conclusion Performing a PN in T3a tumors leads to better survival rates compared to an RN. In tumors <7cm, cT3a does not seem to be a contraindication for a PN. Further data should be analyzed to prove this survival benefit in a larger, multi-institutional cohort.

Renal volume matters: Assessing the association between excisional volume loss and renal function after partial nephrectomy

BACKGROUND/OBJECTIVES

To investigate the oncological and functional outcomes after partial nephrectomy for clinical stage T1 (cT1) renal cell carcinoma (RCC), and assess the association between excisional volume loss (EVL) and postoperative renal function.

METHODS

We retrospectively reviewed 150 patients with cT1 RCC undergoing partial nephrectomy from 2002 to 2016. End-point evaluation was assessed by recurrence free survival (RFS), overall survival (OS), stage III and stage IV chronic kidney disease (CKD). Regression models were used to determine the risk factors of CKD after surgery. The relationship between EVL and renal function decline was evaluated using Spearman correlation method.

RESULTS

Ninety patients with clinical stage T1a (cT1a) tumors and 60 patients with clinical stage T1b (cT1b) tumors were included. There were no differences in RFS, OS, and risk of stage III and stage IV CKD between the two groups. In Cox regression models, multivariate analysis showed that preoperative estimated glomerular filtration rate (eGFR) was an independent risk factor for developing stage III (hazard ratio 0.937, P < 0.001) and stage IV CKD (hazard ratio 0.929, P = 0.027). EVL was significantly associated with postoperative eGFR decrease. (Correlation Coefficient = 0.325, P = 0.003).

CONCLUSIONS

Patients with cT1a and cT1b RCC have comparable oncological and functional outcome after partial nephrectomy, and preoperative eGFR is an independent factor to predict developing CKD. EVL has influence on the postoperative renal function decline.

Percutaneous cryoablation for renal cell carcinoma using ultrasound-guided targeting and computed tomography-guided ice-ball monitoring: radiation dose and short-term outcomes

BACKGROUND

Usefulness of ultrasound (US)-guided mass targeting and computed tomography (CT)-guided ice-ball monitoring in percutaneous cryoablation (PCA) for renal cell carcinoma (RCC) is still uncertain.

PURPOSE

To assess radiation dose and short-term outcomes of PCA for RCC using US-guided targeting and CT-guided ice-ball monitoring.

MATERIAL AND METHODS

Thirty-nine consecutive patients who underwent PCA for biopsy-proven RCC were included. Mass targeting was performed with US and ice-ball was monitored with CT guidance. Effective radiation dose of CT during PCA was recorded. Follow-up was conducted with contrast-enhanced CT or magnetic resonance imaging (MRI) (mean follow-up time = 10.1 ± 7.0 months). Local tumor progression was defined by the presence of focal enhancing areas at the ablation zone (CT, ≥ 20 HU; MRI, presence of focal enhancement on subtraction contrast-enhanced image). Technical success, major complication rate (e.g. Clavien-Dindo classification ≥ 3), and one-year local tumor progression-free survival (PFS) rate were analyzed.

RESULTS

Mean effective radiation dose in association with PCA was 12.1 ± 4.5 mSv (range = 7.0-25.2 mSv). Technical success was achieved in 100%. Local tumor progression occurred in a single patient (2.6%, 1/39), and one-year local tumor PFS rate was 95.7%. No major complication was found.

CONCLUSION

PCA using US-guided targeting and CT-guided ice-ball monitoring may allow acceptable local tumor control for RCC, as a radiation-reducing strategy.

Oncologic Outcomes Following Partial Nephrectomy and Percutaneous Ablation for cT1 Renal Masses

BACKGROUND

Long-term data comparing partial nephrectomy (PN) and thermal ablation are lacking.

OBJECTIVE

To update our experience with PN, percutaneous radiofrequency ablation (RFA), and percutaneous cryoablation for cT1 renal masses.

DESIGN, SETTING, AND PARTICIPANTS

A total of 1798 patients with primary cT1N0M0 renal masses treated between 2000 and 2011 at Mayo Clinic were identified.

INTERVENTION

Percutaneous ablation versus PN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Cancer-specific survival (CSS) was estimated using the Kaplan-Meier method. Local recurrence, metastases, and death from renal cell carcinoma (RCC) were compared with propensity-score-adjusted Cox models.

RESULTS AND LIMITATIONS

Among 1422 cT1a patients, 1055, 180, and 187 underwent PN, RFA, and cryoablation with median clinical follow-up of 9.4, 7.5, and 6.3yr, respectively. Comparisons of RFA with PN resulted in hazard ratios (HRs) of 1.49 (95% confidence interval [CI] 0.55-4.04, p=0.4), 1.46 (95% CI 0.41-5.19, p=0.6), and 1.99 (95% CI 0.29-13.56, p=0.5) for local recurrence, metastases, and death from RCC. Comparisons of cryoablation to PN resulted in HRs of 1.88 (95% CI 0.76-4.66, p=0.18), 0.23 (95% CI 0.03-1.72, p=0.15), and 0.29 (95% CI 0.01-6.11, p=0.4) for these same outcomes. Five-year CSS was 99%, 96%, and 100% for PN, RFA, and cryoablation, respectively. Among 376 cT1b patients, 324 and 52 underwent PN and cryoablation with median clinical follow-up of 8.7 and 6.0yr, respectively. Comparisons of cryoablation with PN resulted in HRs of 1.22 (95% CI 0.33-4.48, p=0.8), 0.95 (95% CI 0.21-4.38, p>0.9), and 1.94 (95% CI 0.42-8.96, p=0.4) for local recurrence, metastases, and death from RCC, respectively. Five-year CSS was 98% and 91% for PN and cryoablation, respectively. Limitations include retrospective review and selection bias.

CONCLUSIONS

With mature follow-up at a single institution, percutaneous ablation appears to have acceptable results for cT1 renal tumors and is appropriate for patients with a contraindication for surgery. For cT1a patients, clinically relevant differences between PN and ablation are unlikely, and treatment choice should involve shared decision making. For cT1b patients, death from RCC was more common with cryoablation, and large differences in this outcome cannot be ruled out. Further research is needed to confirm the oncologic effectiveness of cryoablation in the cT1b setting.

PATIENT SUMMARY

With appropriate patient triage, partial nephrectomy and percutaneous ablation can be used to treat cT1 renal masses, although additional follow-up and further study are still needed.

RENAL nephrometry score: Predicting perioperative outcomes following open partial nephrectomy

Background

Partial nephrectomy has emerged as a standard treatment for small renal masses offering oncologic control equivalent to radical nephrectomy, with preservation of renal function and evidence for equivalent survival. In this study, we evaluated RENAL nephrometry score (RNS) in predicting perioperative outcomes in patients with partial nephrectomy.

Materials and Methods

This was a prospective observational study conducted from February 2016 to August 2017 which included patients who underwent partial nephrectomy. The patients were divided into three groups depending on the complexity scores (low, moderate, and high). Tumors were assigned RNS and tumor-node-metastasis staging of the clinically malignant tumors was done. Blood loss, warm ischemia time (WIT), and surgical complications were assessed.

Results

A total of 20 patients underwent open partial nephrectomy during the study. There were 4 (20%) low, 11 (55%) moderate, and 5 (25%) high-complexity lesions. Blood loss was significantly different in three groups. All the cases in high-complexity group were performed with clamping the renal vessels with a mean WIT of 29 min. The overall complication rates were significantly different between the groups (P = 0.007); however, majority of the complications were low grade (Grades I and II) and were managed conservatively.

Conclusion

In the present study, RNS was correlated with predicting surgical access route, need for clamping during partial nephrectomy, blood loss, decrease in glomerular filtration rate of operated kidneys, postoperative complications, and tumor grade.

Predictive factors for the development of renal insufficiency following partial nephrectomy and subsequent renal function recovery: A multicenter retrospective study

Patients who undergo partial nephrectomy (PN) may exhibit renal function insufficiency, and a subset of these patients achieves renal function recovery. We evaluated the predictors of renal insufficiency and subsequent renal function recovery following PN. Data on 393 patients who underwent PN for solid renal tumors between March 2001 and November 2013, obtained from 6 institutions, were retrospectively reviewed. Renal insufficiency was defined as new onset of chronic kidney disease stage ≥3 postoperatively on the second of 2 consecutive tests. Renal function recovery was defined as an estimated glomerular filtration rate ≥60 ml/minute/1.73 m following renal insufficiency. Tumor complexity was stratified according to the RENAL classification system. The median (interquartile range) age, tumor size, and follow-up period were 53 (45-63) years, 2.6 (1.9-3.8) cm, and 36 (12-48) months, respectively. Tumors were of low complexity in 258/393 (65.6%) of cases. Renal insufficiency developed in 54/393 (13.5%) patients, in which age ≥60 years and preoperative creatinine ≥1.1 mg/ml were independent predictors. Tumor complexity, clamp type, and operative method were not significant prognostic factors. Among patients with newly developed renal insufficiency, 18/54 (33.3%) patients exhibited renal function recovery within a median period of 18 months, of which preoperative creatinine <1.1 mg/ml was an independent predictor. Age ≥60 years and preoperative creatinine ≥1.1 mg/ml were risk factors for renal insufficiency following PN. Patients with renal insufficiency whose preoperative creatinine was <1.1 mg/ml were likely to have renal function recovery.

Magnetic resonance imaging characteristics and changes in hemostatic agents after partial nephrectomy

PURPOSE

To evaluate the characteristics of images generated by magnetic resonance imaging (MRI) and changes in the mass-like lesion (MLL) during the follow-up of patients who underwent partial nephrectomy (PN) with the intra-operative use of hemostatic agents (HAs).

METHODS

The records of patients who had undergone PN in our clinic due to renal mass between January 2013 and August 2018 were retrospectively reviewed. Our study included 47 patients who were administered one or more HAs during the PN and who received diffusion and dynamic MRI at the post-operative 2nd/4th Queryand 12th month.

RESULTS

MLL is defined as T2 heterogeneous, intermediate-signal intensity bolster-related mass with a pseudocapsule in the renal parenchymal defect. When we looked at the morphological changes of MLL, the mean largest axial dimensions of masses were 27.3 (range 12.2-44.7) mm in the first follow-up period (2nd/4th months) and 21.2 (range 11-44.7) mm in the 12th month follow-up period. The average change in size of MLL was - 0.66 mm/month. We did not see any significant relationship between observation of MLL in the post-operative follow-up MRI images and the use of HAs such as Surgicel^®, Spongostan^®, and autologous fatty tissue as well as the amount of the agents used in PN operations (p = 0.405, p = 0.159, respectively).

CONCLUSIONS

The distinction of MLL causing bolster-related mass and granulomatosis tissue from relapse/recurrence can be made based on the change in mass size observed in the MR images and image characteristics.

Treatment Trends and Long-Term Survival Associated with Cryotherapy and Partial Nephrectomy for Small Renal Masses in the National Cancer Database Using Propensity Score Matching

Objective: Trends in the utilization of ablative therapy are unknown for the treatment of small renal masses. Our goal is to utilize the National Cancer Database (NCDB) to both assess the utilization of ablative therapies and long-term survival. Materials and Methods: The NCDB captures 70% of all cancer cases in the United States and was queried between 1998 and 2012 for renal cell carcinomas that were treated with ablative therapy, partial nephrectomy (PN), or radical nephrectomy. The analysis was limited to clinical stage T_1a. Propensity score matching was used in 1:1 fashion. Kaplan-Meier survival analysis and a Cox proportional hazards model were used to compare overall survival (OS) for cryotherapy and PN. Results: A total of 119,240 cases of clinical stage T_1a renal masses were treated between 1998 and 2012. Cryotherapy peaked at 927 (9.1%) cases in 2010 and had 913 (8.4%) in 2012. PN accounted for 18% of the cases in 1998, but surpassed the utilization of nephrectomy in 2008. By 2012, PN accounted for 6766 (62%) of renal mass cases. After matching, Kaplan-Meier OS was lower for cryotherapy compared with PN at 24 (94.5% vs 96.5%), 48 (86.8% vs 90.9%), and 96 months (66.0% vs 74.9%). Cryotherapy also had a lower OS (hazard ratio 1.46; p < 0.001) on adjusted analysis. Conclusion: Cryotherapy for small renal masses plateaued at 9% utilization in 2009. Cryotherapy had a lower OS than PN for tumors >2 cm on adjusted analysis, but this result should be used with caution until confirmed in randomized studies.

"At-risk" kidney: How surgical factors influence renal functional preservation after partial nephrectomy

OBJECTIVES

To investigate the influence of surgical modifiable factors on chronic kidney disease upstaging in a contemporary cohort of patients with normal and "at-risk" kidneys undergoing partial nephrectomy.

METHODS

We reviewed 778 consecutive patients with (n = 634)/without (n = 144) chronic kidney disease or risk factors for chronic kidney disease in our institutional partial nephrectomy database. Chronic kidney disease upstaging was assessed using glomerular filtration rate measurements preoperatively and at 3-12 months postoperatively. Using a multivariate logistic regression, baseline clinicodemographic factors, and the operative measurements of excisional volume loss and warm and cold ischemia time on rates of chronic kidney disease upstaging were determined. Marginal effects were used to analyze the impact of ischemia time and generate interaction curves.

RESULTS

Chronic kidney disease/risk factors for chronic kidney disease had equivalent rates of chronic kidney disease upstaging as the healthy kidney cohort (31.5% vs 38.2%, P = 0.15). Of the entire cohort, 2.8% were upstaged to stage IV-V chronic kidney disease. Multivariate analysis found a significant association between chronic kidney disease upstaging and excisional volume loss in both cohorts (no chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.63, P = 0.04; chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.42, P = 0.001). Only in the chronic kidney disease/risk factors for chronic kidney disease cohort, there was an association between ischemia type/duration and chronic kidney disease upstaging (odds ratio 1.04, P = 0.04). Warm ischemia began to predict an increased risk of chronic kidney disease upstaging at 17.6 min, which became statistically significant at 49 min.

CONCLUSIONS

Chronic kidney disease upstaging is common after partial nephrectomy. Although volume loss unequivocally affects rates of upstaging irrespective of baseline renal function, warm ischemia time disproportionately influences "at-risk" kidneys. Therefore, strong consideration should be given to minimizing volume loss and using cold ischemia when extended clamp times are anticipated in "at-risk" kidneys.

Comparing Off-clamp and On-clamp Robot-assisted Partial Nephrectomy: A Prospective Randomized Trial

OBJECTIVE

To determine whether performing robot-assisted partial nephrectomy without warm ischemia "off-clamp" results in favorable postoperative renal functional outcomes compared with the on-clamp method.

METHODS

We conducted a prospective trial of 80 patients who underwent robot-assisted partial nephrectomy. They were randomized in a 1:1 ratio to undergo the procedure with renal artery clamping or without clamping. The groups were compared across demographics, operative information, perioperative outcomes, and postoperative renal function. We assessed renal function by estimated glomerular filtration rate and renal scintigraphy both preoperatively and at 3 months postoperatively.

RESULTS

Patients in the on-clamp and off-clamp groups were similar in age, gender, body mass index, comorbidities, clinical tumor size, nephrometry score, and laterality. Off-clamp procedures were lengthier at an average 178.0 minutes vs 156.0 minutes for on-clamp (P = .011). Estimated blood loss, rates of pelvicalyceal repair, postoperative complications, and positive margins were not different. At a median 3-month follow-up, no significant differences were seen in change in postoperative estimated glomerular filtration rate or percent split renal function between both groups.

CONCLUSION

In this prospective study, off-clamp robot-assisted partial nephrectomy resulted in similar perioperative outcomes compared with the on-clamp technique. No benefit was demonstrated in the preservation of renal function. Urologists may safely employ either an on-clamp or off-clamp strategy depending on surgeon preference and patient-specific factors including baseline renal insufficiency, multiple masses, or solitary kidney.

Renal hypothermia during partial nephrectomy for patients with renal tumours: a randomised controlled clinical trial protocol

INTRODUCTION

Partial nephrectomy is a standard of care for non-metastatic renal tumours when technically feasible. Despite the increased use of partial nephrectomy, intraoperative techniques that lead to optimal renal function after surgery have not been rigorously studied. Clamping of the renal hilum to prevent bleeding during resection causes temporary renal ischaemia. The internal temperature of the kidney may be lowered after the renal hilum is clamped (renal hypothermia) in an attempt to mitigate the effects of ischaemia. Our objective is to determine if renal hypothermia during open partial nephrectomy results in improved postoperative renal function at 12 months following surgery as compared with warm ischaemia (no renal hypothermia).

METHODS AND ANALYSES

This is a multicentre, randomised, single-blinded controlled trial comparing renal hypothermia versus no hypothermia during open partial nephrectomy. Due to the nature of the intervention, complete blinding of the surgical team is not possible; however, surgeons will be blinded until the time of hilar clamping. Glomerular filtration will be based on plasma clearance of a radionucleotide, and differential renal function will be based on renal scintigraphy. The primary outcome is overall renal function at 12 months measured by the glomerular filtration rate (GFR). Secondary outcomes include change in GFR, GFR of the affected kidney, change in GFR of the affected kidney, serum creatinine, haemoglobin, spot urine albumin to creatinine ratio, quality of life and postoperative complications. Data will be collected at baseline, immediately postoperatively and at 3, 6, 9 and 12 months postoperatively.

ETHICS AND DISSEMINATION

Ethics approval was obtained for all participating study sites. Results of the trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT01529658; Pre-results.

Evaluation of Urinary Renal Biomarkers for Early Prediction of Acute Kidney Injury Following Partial Nephrectomy: A Feasibility Study

BACKGROUND

Partial nephrectomy (PN) is the gold standard for the treatment of small renal masses. Urinary biomarkers (UBMs) may serve as early indicators of acute kidney injury (AKI) following PN.

OBJECTIVE

To evaluate the timing, specificity, and sensitivity of several candidate UBMs after PN to determine the most promising UBMs in this setting. We hypothesize that some UBMs will have utility as early markers of AKI.

DESIGN, SETTING, AND PARTICIPANTS

Twenty-two patients undergoing on-clamp robotic or open PN underwent paired urine collection via ureteral catheterization of the affected kidney and Foley catheterization for the unaffected kidney obtained preoperatively, after anesthesia, and at several points in time after renovascular occlusion.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Measured UBMs included albumin, α-glutathione S-transferase, B2M, calbindin, clusterin, cystatin C, epidermal growth hormone, kidney injury molecule 1, neutrophil gelatinase-associated lipocalin, osteoactivin, osteopontin, total protein, trefoil factor 3, uromodulin, and vascular endothelial growth factor.

RESULTS AND LIMITATIONS

The largest fold changes in UBM levels were observed between the baseline values and just prior to vascular occlusion (time "0"). Albumin, clusterin, and calbindin were among the most consistently and significantly increased UBMs. After vascular occlusion and subsequent reperfusion, some UBMs, most notably albumin, calbindin, and total protein, continued to increase in the affected kidney, peaking at 60-90min, followed by decrease to time "0" measurements after 1 d and to baseline levels 14-42 d after surgery. No striking association of UBMs with parameters such as duration of surgery, ischemia time, and tumor complexity was observed.

CONCLUSIONS

The most significant UBM increases were observed when comparing samples obtained at preoperative visit and after anesthesia, but before clamp time. Albumin, clusterin, and calbindin were the most consistently and significantly altered UBMs; further investigation will be necessary to determine whether UBMs can identify AKI earlier in nephrectomy patients.

PATIENT SUMMARY

Factors (biomarkers) measured in the blood or urine can indicate the presence and amount of kidney injury. We evaluated 15 different biomarkers at several points in time prior to, during, and after surgery for kidney cancer. We found that three of these biomarkers were most consistently elevated in patients undergoing partial nephrectomy. Interestingly, the largest increases were observed when comparing samples obtained prior to surgery with those obtained just after anesthesia.

Age at diagnosis and the surgical management of small renal carcinomas: findings from a cross-sectional population-based study

OBJECTIVES

To describe the use of partial nephrectomy (PN) for patients with stage T1a renal cell carcinoma (RCC) by age group (<65 and ≥65 years) in two Australian states.

MATERIALS AND METHODS

All adults diagnosed with RCC in 2012 and 2013 were identified through population-based cancer registries in the Australian states of Queensland and Victoria. For each patient, research assistants extracted patient, tumour and treatment data from medical records. Percentages of patients treated by PN were determined for the two age groups. Multivariable logistic regression analyses examined factors associated with PN. Clinicians treating RCC were sent surveys to assess attitudes towards PN.

RESULTS

Data were collected on 956 patients (Victoria: n = 548; Queensland: n = 404) with stage T1a RCC. Of those undergoing surgery (n = 865), PN was more common for those aged <65 years (61%) than for those aged ≥65 years (44%), with this difference significant after adjusting for patient, tumour (odds ratio 0.50, 95% confidence interval 0.36-0.70). There were significant interactions between age and treatment centre volume (P < 0.05) and residential state (P < 0.05). PN was less likely for younger patients treated at lower-volume hospitals (<24 patients a year) but hospital volume was not associated with PN for older patients. PN was less likely for older patients in Queensland than Victoria. In multivariable analyses, age was not related to laparoscopic surgery. Queensland clinicians were less likely than those from Victoria to agree that PN was the treatment of choice for most T1aN0M0 tumours (P < 0.001).

CONCLUSIONS

In Australia, patients aged > 65 years with small renal cancers were less likely to be treated by PN than younger patients. The variation in the surgical procedure used to treat older T1a RCC patients by state and hospital volume indicates that better evidence is needed to direct practice in this area.

Classification tree for the prediction of malignant disease and the prediction of non-diagnostic biopsies in patients with small renal masses

INTRODUCTION

Preoperative prediction of benign vs. malignant small renal masses (SRMs) remains a challenge. This study: 1) validates our previously published classification tree (CT) with an external cohort; 2) creates a new CT with the combined cohort; and 3) evaluates the RENAL and PADUA scoring systems for prediction of malignancy.

METHODS

This study includes a total of 818 patients with renal masses; 395 underwent surgical resection and 423 underwent biopsy. A CT to predict benign disease was developed using patient and tumour characteristics from the 709 eligible participants. Our CT is based on four parameters: tumour volume, symptoms, gender, and symptomatology. CART modelling was also used to determine if RENAL and PADUA scoring could predict malignancy.

RESULTS

When externally validated with the surgical cohort, the predictive accuracy of the old CT dropped. However, by combining the cohorts and creating a new CT, the predictive accuracy increased from 74% to 87% (95% confidence interval 0.84-0.89). RENAL and PADUA score alone were not predictive of malignancy. One limitation was the lack of available histological data from the biopsy series.

CONCLUSIONS

The validated old CT and new combined-cohort CT have a predictive value greater than currently published nomograms and single-biopsy cohorts. Overall, RENAL and PADUA scores were not able to predict malignancy.

[Partial nephrectomy for renal masses >7cm: Morbidity, oncological and functional outcomes (UroCCR-7 study)]

OBJECTIVES

To describe the morbidity, mortality, oncological and functional results of Partial nephrectomy (PN) for the treatment of renal tumors of more than 7cm.

MATERIAL AND METHODS

Thirty-seven partial nephrectomies for tumors larger than 7cm operated in a single center between 1987 and 2016 were analyzed retrospectively. The pre, per and postoperative clinico-biological data were collected within the UroCCR database. The GFR was assessed at day 5, 1 month and last follow-up. Intraoperative and postoperative surgical complications, the recurrence rate and the overall and specific mortality were collected.

RESULTS

The mean age of the patients was 57 years (44-68). The preoperative GFR and the median tumor size were 80mL/min and 8cm, respectively. The indication for surgery was elective in 21 cases (60%) and 19 tumors (54%) were malignant. Postoperative complications occurred in 24,3 cases (24.3%). The median post-operative GFR was respectively 77mL/min, 80mL/min and 77mL/min at day 5, 1month and at last follow-up. With a median follow up of 31 months [1-168], 5 patients (26,3%) had metastatic progression of whom 1 (5.3%) had a concomitant local recurrence and 3 (15.8%) had died from cancer.

CONCLUSION

This study confirms the feasibility of PN for large tumors with acceptable morbidity, limited risk of local recurrence and excellent functional results.

LEVEL OF EVIDENCE

4.

Image-guided minimally invasive treatment for small renal cell carcinoma

Surgical partial nephrectomy is still considered as the "gold standard" for the definitive management of small malignant renal masses, whereas treatment with image-guided percutaneous ablation is still mainly reserved for those patients who cannot undergo nephron-sparing surgical resection due to advanced age, underlying comorbidities or compromised renal function. Nonetheless, the recent evidence that underlines the long-term oncological equipoise of percutaneous ablation methods with surgical resection in combination with the reduced complication rate and cost supports the use of an image-guided minimally invasive approach as a first-line treatment. The purpose of this review is to offer an overview of the most widely used percutaneous renal ablation treatments (radiofrequency, microwave and cryoablation) with a focus on their main technical aspects and application techniques for curative ablation of small renal cell carcinoma (stage cT1a). The authors also provide a critical narrative of the relevant medical literature with an emphasis on outcomes of comparative effectiveness research, and appraise the percutaneous methods compared to surgery in the context of evidence-based practice and future research studies.

TEACHING POINTS

• RCC is a common cancer and is increasingly detected incidentally at early stages. • There is long-term oncological equipoise of percutaneous ablation compared to surgical resection. • Large-scale trials are required to produce Level 1a evidence.

Predictors of new-onset chronic kidney disease in patients managed surgically for T1a renal cell carcinoma: An Australian population-based analysis

BACKGROUND

New-onset chronic kidney disease (CKD) following surgical management of kidney tumors is common. This study evaluated risk factors for new-onset CKD after nephrectomy for T1a renal cell carcinoma (RCC) in an Australian population-based cohort.

METHODS

There were 551 RCC patients from the Australian states of Queensland and Victoria included in this study. The primary outcome was new-onset CKD (eGFR <60 mL/min per 1.73 m² ) and the secondary outcome was new-onset moderate-severe CKD (<45 mL/min per 1.73 m² ). Multivariable logistic regression was used to evaluate associations between patient, tumor and health-service characteristics and these outcomes.

RESULTS

Forty percent (219/551) of patients developed new-onset CKD, and 12% (68/551) experienced new-onset moderate-severe CKD. Risk factors for new-onset CKD were age, lower preoperative eGFR, tumor size >20 mm, radical nephrectomy, lower hospital caseloads (<20 cases/year), and rural place of residence. The associations between rural place of residence and low center volume were a consequence of higher radical nephrectomy rates.

CONCLUSION

Risk factors for CKD after nephrectomy generally relate to worse baseline health, or likelihood of undergoing radical nephrectomy. Surgeons in rural centres and hospitals with low caseloads may benefit from formalized integration with specialist centers for continued professional development and case-conferencing, to assist in management decisions.

Prospective study of robotic partial nephrectomy for renal cancer in Japan: Comparison with a historical control undergoing laparoscopic partial nephrectomy

OBJECTIVES

To evaluate the outcomes of robotic partial nephrectomy compared with those of laparoscopic partial nephrectomy for T1 renal tumors in Japanese centers.

METHODS

Patients with a T1 renal tumor who underwent robotic partial nephrectomy were eligible for inclusion in the present study. The primary end-point consisted of three components: a negative surgical margin, no conversion to open or laparoscopic surgery and a warm ischemia time ≤25 min. We compared data from these patients with the data from a retrospective study of laparoscopic partial nephrectomy carried out in Japan.

RESULTS

A total of 108 patients were registered in the present study; 105 underwent robotic partial nephrectomy. The proportion of patients who met the primary end-point was 91.3% (95% confidence interval 84.1-95.9%), which was significantly higher than 23.3% in the historical data. Major complications were seen in 19 patients (18.1%). The mean change in the estimated glomerular filtration rate in the operated kidney, 180 days postoperatively, was -10.8 mL/min/1.73 m² (95% confidence interval -12.3-9.4%).

CONCLUSIONS

Robotic partial nephrectomy for patients with a T1 renal tumor is a safe, feasible and more effective operative method compared with laparoscopic partial nephrectomy. It can be anticipated that robotic partial nephrectomy will become more widely used in Japan in the future.

Outcomes of pathologic stage T3a renal cell carcinoma up-staged from small renal tumor: emphasis on partial nephrectomy

Background

The prognosis of patients with pathologic stage T3a renal cell carcinoma (RCC) that is up-staged from a small renal tumor remains controversial. We evaluated the prognosis of patients with RCC who were up-staged from clinical stage T1 to pathologic stage T3a.

Methods

We retrospectively reviewed the data of 3431 patients who were surgically treated for clinical stage T1 RCC. The survival outcomes were compared using Kaplan-Meier and Cox proportional analyses.

Results

Among the clinical stage T1 patients, 215 (6.3%) were finally up-staged to pathologic stage T3a. Patient age (HR 1.302, 95% CI 1.018–1.046, p <  0.001), tumor diameter (HR 1.686, 95% CI 1.551–1.834, p <  0.001), and hilar location (HR 1.765, 95% CI 1.147–2.715, p = 0.010) were significantly associated with upstaging. Kaplan-Meier analyses showed significantly shorter recurrence-free, cancer-specific and overall survivals (all p <  0.001) in patients who were up-staged. Multivariate Cox analyses revealed pathologic upstaging as an independent predictor of shorter recurrence-free (HR 2.195, 95% CI 1.459–3.300, p <  0.001), cancer-specific (HR 2.238, 95% CI 1.252–4.003, p = 0.007), and overall survivals (HR 1.632, 95% CI 1.029–2.588, p = 0.037). Subgroup analysis of pathologic stage T3a showed no significant difference in survival of the partial nephrectomy group when compared to the radical nephrectomy group (all p > 0.5).

Conclusions

Patients up-staged from clinical stage T1 to pathologic stage T3a RCC showed shorter survival outcomes than those without upstaging. However, partial nephrectomy, compared with radical nephrectomy, showed comparable outcomes in patients who were up-staged.

Evaluation of Quantitative and Qualitative Renal Outcome Following Nephron Sparing Surgery

Purpose:

Preservation of renal function after nephron-sparing surgery (NSS) is multifactorial and the impact of individual factors on it is still a debate. This prospective study investigates the impact of factors responsible for quantitative and functional outcome after NSS.

Patients and Methods:

Fifty-two patients of localized renal mass (≤7 cm) were included in the study. A contrast-enhanced computed tomography abdomen was performed for characterization of tumor. Glomerular filtration rate (GFR) was calculated using Tc99m-diethylenetriamine pentaacetic acid (DTPA) scan and Cockcroft-Gault (CG) formula. All relevant intra- and peri-operative events were noted. Follow-up work up performed at 3 months.

Results:

Overall, the mean ischemia time was 30.6 min, with 7.7% decrease in renal volume in the operated moiety. In follow-up, the total and ipsilateral GFR decreased. Change in renal parenchymal volume, total GFR by CG and DTPA, split GFR of tumor-bearing moiety was significant in follow-up. Size, stage, polar location of tumor, duration of surgery, type of ischemia, preoperative chronic kidney disease, and need of blood transfusion did not affect change in renal volume and function in the follow-up period.

Conclusion:

Renal parenchymal loss and duration of ischemia have impact on the follow-up renal function.

Radiofrequency Ablation of Small Renal Masses: Outcomes, Complications and Effects on Renal Function

Introduction

To describe oncological outcomes, effects on renal function and complications with radiofrequency ablation (RFA) of T1 renal tumors in an 8-year experience.

Materials and Methods

A retrospective study of RFA in 89 consecutive patients between 2005 and 2013 was undertaken. Those with metastatic disease, incomplete follow-up, genetic pre-disposition to renal tumors and biopsy proven benign pathology were excluded, with 79 patients meeting inclusion criteria. Data was collected on demographics, oncological outcomes, complications and effects on renal function.

Results

We demonstrate 94% disease-free survival at median follow-up of 29 months in a population consisting of 42 T1a and 37 T1b tumors. No disease related deaths were recorded in the follow-up period. Post-RFA decline in renal function was shown to correlate with tumor size and increased age (p = 0.0009/0.0021). Pre-existing renal impairment was a risk for post-RFA function decline (p < 0.005). Two complications were encountered in the series.

Conclusion

RFA produces durable oncological outcomes in T1 tumors with a minimal effect on renal function and low risk of complications. Patients at risk of developing renal impairment can be identified from described risk factors.

Multiple application of three-dimensional soft kidney models with localized kidney cancer: A pilot study

Aim:

To evaluate the effectiveness of three-dimensional printing application in urology for localized renal cancer treatment using three-dimensional printed soft models.

Materials and methods:

The study included five patients with kidney tumors. The patients were treated in the Urology Clinic of I.M. Sechenov First Moscow State Medical University from February 2016 to June 2017. Personalized three-dimensional printed models based on computed tomographic images were created. Five surgeons took part in a survey in which the utility of computed tomographic images versus three-dimensional printed models for presurgical planning was compared. A laparoscopic partial nephrectomy training using the developed three-dimensional printed models was performed by the same surgeons in a surgical training box.

Results:

The patients underwent endoscopic surgery using laparoscopic access. The average time of surgery was 187 min. All the operations were performed with complete renal artery clamping. The average warm ischemia time was 19.5 min and the average blood loss was 170 mL. No conversions to open surgery or radical nephrectomy, and no postoperative complications and deaths were observed. All the surgical margins were negative. The tumors were morphologically identified as renal cell carcinoma in four cases and as oncocytoma in one case.

Conclusion:

The developed three-dimensional printed models allow one to evaluate the pathological anatomy of tumors more effectively. High similarity between three-dimensional models and native kidneys contribute to improvement of surgical skills necessary for partial nephrectomy. Training on the three-dimensional models also allows surgeons to facilitate selection of an optimal surgical tactics for each patient.