Clinical practice. Small renal mass

The Zhongshan score: a novel and simple anatomic classification system to predict perioperative outcomes of nephron-sparing surgery

In the zero ischemia era of nephron-sparing surgery (NSS), a new anatomic classification system (ACS) is needed to adjust to these new surgical techniques. We devised a novel and simple ACS, and compared it with the RENAL and PADUA scores to predict the risk of NSS outcomes. We retrospectively evaluated 789 patients who underwent NSS with available imaging between January 2007 and July 2014. Demographic and clinical data were assessed. The Zhongshan (ZS) score consisted of three parameters. RENAL, PADUA, and ZS scores are divided into three groups, that is, high, moderate, and low scores. For operative time (OT), significant differences were seen between any two groups of ZS score and PADUA score (all P < 0.05). For ZS score, patients with moderate and high scores had longer warm ischemia time (WIT) and greater increase in SCr compared with low score (all P < 0.05). What is more, the differences between moderate and high scores classified by ZS score were borderline but trending toward significance in WIT (P = 0.064) and increase in SCr (P = 0.052). Interestingly, RENAL showed no significant difference between moderate and high complexity in OT, WIT, estimated blood loss, and increase in SCr. Compared with patients with a low score of ZS, those with a high or moderate score had 8.1-fold or 3.3-fold higher risk of surgical complications, respectively (all P < 0.05). As for RENAL score, patients with a high or moderate score had 5.7-fold or 1.9-fold higher risk of surgical complications, respectively (all P < 0.05). Patients with a high or moderate score of PADUA had 2.3-fold or 2.8-fold higher risk of surgical complications, respectively (all P < 0.05). In the ROC curve analysis, ZS score had the greatest AUC for surgical complications (AUC = 0.632) and the conversion to radical nephrectomy (AUC = 0.845) (all P < 0.05). In conclusion, the ability of ZS score to predict the surgical complexity and surgical complications of NSS is better than RENAL and PADUA scores. ZS score could be used to reflect the surgical complexity and predict the risk of surgical complications in patients undergoing NSS.

EAU guidelines on renal cell carcinoma: 2014 update

CONTEXT

The European Association of Urology Guideline Panel for Renal Cell Carcinoma (RCC) has prepared evidence-based guidelines and recommendations for RCC management.

OBJECTIVES

To provide an update of the 2010 RCC guideline based on a standardised methodology that is robust, transparent, reproducible, and reliable.

EVIDENCE ACQUISITION

For the 2014 update, the panel prioritised the following topics: percutaneous biopsy of renal masses, treatment of localised RCC (including surgical and nonsurgical management), lymph node dissection, management of venous thrombus, systemic therapy, and local treatment of metastases, for which evidence synthesis was undertaken based on systematic reviews adhering to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Relevant databases (Medline, Cochrane Library, trial registries, conference proceedings) were searched (January 2000 to November 2013) including randomised controlled trials (RCTs) and retrospective or controlled studies with a comparator arm. Risk of bias (RoB) assessment and qualitative and quantitative synthesis of the evidence were performed. The remaining sections of the document were updated following a structured literature assessment.

EVIDENCE SYNTHESIS

All chapters of the RCC guideline were updated. For the various systematic reviews, the search identified a total of 10,862 articles. A total of 151 studies reporting on 78,792 patients were eligible for inclusion; where applicable, data from RCTs were included and meta-analyses were performed. For RCTs, there was low RoB across studies; however, clinical and methodological heterogeneity prevented data pooling for most studies. The majority of studies included were retrospective with matched or unmatched cohorts based on single or multi-institutional data or national registries. The exception was for systemic treatment of metastatic RCC, in which several RCTs have been performed, resulting in recommendations based on higher levels of evidence.

CONCLUSIONS

The 2014 guideline has been updated by a multidisciplinary panel using the highest methodological standards, and provides the best and most reliable contemporary evidence base for RCC management.

PATIENT SUMMARY

The European Association of Urology Guideline Panel for Renal Cell Carcinoma has thoroughly evaluated available research data on kidney cancer to establish international standards for the care of kidney cancer patients.

Imaging findings of common benign renal tumors in the era of small renal masses: differential diagnosis from small renal cell carcinoma: current status and future perspectives

The prevalence of small renal masses (SRM) has risen, paralleling the increased usage of cross-sectional imaging. A large proportion of these SRMs are not malignant, and do not require invasive treatment such as nephrectomy. Therefore, differentation between early renal cell carcinoma (RCC) and benign SRM is critical to achieve proper management. This article reviews the radiological features of benign SRMs, with focus on two of the most common benign entities, angiomyolipoma and oncocytoma, in terms of their common imaging findings and differential features from RCC. Furthermore, the role of percutaneous biopsy is discussed as imaging is yet imperfect, therefore necessitating biopsy in certain circumstances to confirm the benignity of SRMs.

Safety and Postoperative Outcomes of Regional versus Global Ischemia for Partial Nephrectomy: A Systematic Review and Meta-Analysis

OBJECTIVE

To analyze current evidence comparing the safety and outcomes of regional and global ischemia for partial nephrectomy (PN).

MATERIALS AND METHODS

A systematic search of the PubMed and Web of Science databases was conducted in May 2014 to identify studies comparing the safety and outcomes of regional and global ischemia for PN. A systematic review and meta-analysis was also performed.

RESULTS

Six retrospective observational studies were selected for the analysis, including 363 patients who underwent PN (162 regional ischemia and 201 global ischemia cases). Operation times were not statistically different [weighted mean difference (WMD) = 20.35 min, 95% CI: -0.28-40.97, p = 0.05], but estimated blood loss was significantly higher in the regional ischemia group (WMD = 52.04 ml, 95% CI: 14.30-89.78, p = 0.007) than in the global ischemia group. Complication rates [odds ratio (OR) = 1.16; 95% CI: 0.63-2.15, p = 0.63] and blood transfusion rates (OR = 1.85; 95% CI: 0.86-4.01, p = 0.12) of the two groups were not significantly different. The regional ischemia group showed better postoperative renal function (WMD = 4.23 ml/min, 95% CI: 2.61-5.85, p < 0.00001) than the global ischemia group, and all cases in the regional ischemia group showed negative margins.

CONCLUSIONS

Regional ischemia is as safe to perform as global ischemia, and the former leads to better postoperative renal functions than the latter. These findings support the application of regional ischemia for PN.

Cystatin C for early detection of acute kidney injury after laparoscopic partial nephrectomy

Introduction and Objectives:

Mortality due to AKI has not changed significantly over the past 50 years. This is due in part to failure to detect early AKI and to initiate appropriate therapeutic measures. There is therefore a need to identify biomarkers that would improve the early detection of AKI. The objective of this study was to assess whether cystatin C levels obtained at specific timepoints during laparoscopic partial nephrectomy (PN) could be early predictors of AKI.

Materials and Methods:

Twenty-five patients underwent laparoscopic PN for organ-confined tumors. All procedures were performed by two surgeons in a single institution. Plasma samples were collected preoperatively, and post-unclamping at 5, 20, 120 min and on the day following surgery. Plasma cystatin C was measured by enzyme-linked immunosorbent assay. Correlation between levels of cystatin C and other parameters of interest were assessed in order to define cystatin C ability to predict AKI and loss of renal function following laparoscopic PN.

Results:

The mean baseline eGFR was 93 ml/min/1.73 m². Warm ischemia time varied between 16 and 44 min. Post-operative day 1 (POD1) cystatin C levels compared to baseline were increased in 13 (52%) of the patients. There was a high correlation between the difference of POD 1 and baseline value, and eGFR in the immediate postoperative period (r = −0.681; P = 0.0002) and at 12-month follow-up (r = −0.460, P = 0.048). However, the variation in cystatin C levels at earlier timepoints were not associated to AKI nor renal function.

Conclusions:

High increase in POD 1 cystatin C levels from baseline may help identify patients with AKI and those at higher risk of chronic kidney disease, following laparoscopic PN.

Heterogeneity and renal mass biopsy: a review of its role and reliability

Increased abdominal imaging has led to an increase in the detection of the incidental small renal mass (SRM). With increasing recognition that the malignant potential of SRMs is heterogeneous, ranging from benign (15%-20%) to aggressive (20%), enthusiasm for more conservative management strategies in the elderly and infirmed, such as active surveillance (AS), have grown considerably. As the management of the SRM evolves to incorporate ablative techniques and AS for low risk disease, the role of renal mass biopsy (RMB) to help guide individualized therapy is evolving. Historically, the role of RMB was limited to the evaluation of suspected metastatic disease, renal abscess, or lymphoma. However, in the contemporary era, the role of biopsy has grown, most notably to identify patients who harbor benign lesions and for whom treatment, particularly the elderly or frail, may be avoided. When performing a RMB to guide initial clinical decision making for small, localized tumors, the most relevant questions are often relegated to proof of malignancy and documentation (if possible) of grade. However, significant intratumoral heterogeneity has been identified in clear cell renal cell carcinoma (ccRCC) that may lead to an underestimation of the genetic complexity of a tumor when single-biopsy procedures are used. Heterogeneous genomic landscapes and branched parallel evolution of ccRCCs with spatially separated subclones creates an illusion of clonal dominance when assessed by single biopsies and raises important questions regarding how tumors can be optimally sampled and whether future evolutionary tumor branches might be predictable and ultimately targetable. This work raises profound questions concerning the genetic landscape of cancer and how tumor heterogeneity may affect, and possibly confound, targeted diagnostic and therapeutic interventions. In this review, we discuss the current role of RMB, the implications of tumor heterogeneity on diagnostic accuracy, and highlight promising future directions.

Significant impact of R.E.N.A.L. nephrometry score on changes in postoperative renal function early after robot-assisted partial nephrectomy

BACKGROUND

Our objective was to evaluate the significance of the R.E.N.A.L. nephrometry score (RNS)--developed to quantitatively evaluate the complexity of renal tumors in a reproducible manner--in perioperative and renal functional outcomes following robot-assisted partial nephrectomy (RAPN).

METHODS

This study assessed 48 consecutive patients with renal tumors who underwent RAPN. Preoperative RNS for each patient was calculated, and its impact on several parameters associated with perioperative outcomes, including postoperative renal function, was investigated with Spearman's rank correlation test.

RESULTS

Mean RNS in the 48 patients was 6.8; of these 48 patients, 21 (43.7%), 24 (50.0%), and three (6.3%) were classified into low-, moderate-, and high-complexity groups, respectively. The RNS was significantly correlated with resected tumor weight and postoperative changes in estimated glomerular filtration rate (eGFR) at both 1 and 4 weeks--but not age, body mass index (BMI), preoperative eGFR, operative time, warm ischemia time, estimated blood loss, postoperative complications, or eGFR-- after RAPN. No component of the RNS (R: radius; E: exophytic/endophytic properties; N: nearness of tumor to the collecting system or sinus; A: anterior/posterior; L: location relative to polar lines) alone had a significant impact on postoperative changes in eGFR at 1 and 4 weeks, whereas resected tumor weight was significantly associated with the R and E subcategories.

CONCLUSIONS

Measurement of total RNS is useful for predicting renal functional outcomes early after RAPN.

Current status of renal biopsy for small renal masses

Small renal masses (SRMs) are defined as radiologically enhancing renal masses of less than 4 cm in maximal diameter. The incidence of renal cell carcinoma (RCC) has increased in recent years, which is mainly due to the rise in incidental detection of localized SRMs. However, the cancer-specific mortality rate is not increasing. This discrepancy may be dependent on the indolent nature of SRMs. About 20% of SRMs are benign, and smaller masses are likely to have pathologic characteristics of low Fuhrman grade and clear cell type. In addition, SRMs are increasingly detected in elderly patients who are likely to have comorbidities and are a high-risk group for active treatment like surgery. As the information about the nature of SRMs is improved and management options for SRMs are expanded, the current role of renal mass biopsy for SRMs is also expanding. Traditionally, renal mass biopsy has not been accepted as a standard diagnostic tool in the clinical scenario because of several issues about safety and accuracy. However, current series on SRM biopsy have reported high diagnostic accuracy with rare complications. Studies of modern SRM biopsy have reported diagnostic accuracy greater than 90% with very high specificity. Also, current series have shown very rare morbid cases caused by renal mass biopsy. Currently, renal biopsy of SRMs can be recommended in most cases except when patients have imaging or clinical characteristics indicative of pathology and in cases in which conservative management is not considered.

Comparison of robotic and open partial nephrectomy: Single-surgeon matched cohort study

INTRODUCTION

We present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or open partial nephrectomy (OPN) by a single surgeon at a single institution.

METHODS

We reviewed the medical records of 200 patients who underwent RPN (n = 100) or OPN (n = 100) between May 2003 and May 2013. The patients who underwent RPN were matched for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, as well as tumour size, side and location. Perioperative outcomes were compared.

RESULTS

There was no significant difference between the 2 cohorts with respect to patient age, BMI, ASA score, preoperative glomerular filtration rate, tumour size and the R.E.N.A.L. nephrometry score. The mean operative time was longer in the RPN group, but there were no significant differences with respect to warm ischemic time and postoperative renal function. The length of hospitalization and use of postoperative analgesics (ketoprofen) were more favourable in the RPN cohort. There was no significant difference in the mean estimated blood loss, transfusion rate, or complications between the cohorts.

CONCLUSIONS

Considering the perioperative and postoperative parameters, RPN is a viable option as a nephron-sparing surgical procedure for small renal masses that yields outcomes comparable to those achieved with OPN. Despite matched cohort analysis among patients who underwent PN by a single surgeon, there may be inherent selection bias; therefore future prospective trials are needed.

CT perfusion in the characterisation of renal lesions: an added value to multiphasic CT

OBJECTIVE

To prospectively evaluate if computed tomography perfusion (CTp) could be a useful tool in addition to multiphasic CT in renal lesion characterisation.

MATERIALS AND METHODS

Fifty-eight patients that were scheduled for surgical resection of a renal mass with a suspicion of renal cell carcinoma (RCC) were enrolled. Forty-one out of 58 patients underwent total or partial nephrectomy after CTp examination, and a pathological analysis was obtained for a total of 49 renal lesions. Perfusion parameters and attenuation values at multiphasic CT for both lesion and normal cortex were analysed. All the results were compared with the histological data obtained following surgery.

RESULTS

PS and MTT values were significantly lower in malignant lesions than in the normal cortex (P < 0.001 and P = 0.011, resp.); PS, MTT, and BF values were also statistically different between oncocytomas and malignant lesions. According to ROC analysis, the accuracy, sensitivity, and specificity to predict RCC were 95.92%, 100%, and 66.7%, respectively, for CTp whereas they were 89.80%, 93.35%, and 50%, respectively, for multiphasic CT.

CONCLUSION

A significant difference between renal cortex and tumour CTp parameter values may suggest a malignant renal lesion. CTp could represent an added value to multiphasic CT in differentiating renal cells carcinoma from oncocytoma.

Landmarks in the diagnosis and treatment of renal cell carcinoma

The most common renal cancer is renal cell carcinoma (RCC), which arises from the renal parenchyma. The global incidence of RCC has increased over the past two decades by 2% per year. RCC is the most lethal of the common urological cancers: despite diagnostic advances, 20-30% of patients present with metastatic disease. A clearer understanding of the genetic basis of RCC has led to immune-based and targeted treatments for this chemoresistant cancer. Despite promising results in advanced disease, overall response rates and durable complete responses are rare. Surgery remains the main treatment modality, especially for organ-confined disease, with a selective role in advanced and metastatic disease. Smaller tumours are increasingly managed with biopsy, minimally invasive interventions and surveillance. The future promises multimodal, integrated and personalized care, with further understanding of the disease leading to new treatment options.

Flank muscle volume changes after open and laparoscopic partial nephrectomy

PURPOSE

To determine the occurrence of flank symptoms, flank muscle atrophy, bulge, and hernia formation after open and laparoscopic partial nephrectomy (LPN).

PATIENTS AND METHODS

Our prospective Institutional Review Board-approved database was queried to identify 50 consecutive patients who were treated with open partial nephrectomy (OPN) and 50 consecutive patients who were treated with LPN between September 2006 and May 2008. Study patients had: Solitary clinical T1 renal tumor, preoperative and ≥6 month postoperative CT scan performed at our institution, and a confirmed renal-cell carcinoma on the final pathology report. Patients with previous abdominal surgery and neuromuscular disorders were excluded. Oncocare software was used to measure abdominal wall musculature on preoperative and postoperative CT scan. Bilateral flanks were compared for muscle volume, bulge, and hernia. Patients were administered a phone questionnaire to assess postoperative flank symptoms.

RESULTS

No statistical significant difference was found in the demographics between the two groups. Median age (range) was 59.9 years (20.6-80.7) in the OPN group and 57.5 years (25-78) in the LPN group (P=0.89). Median (range) body mass index and American Society of Anesthesiologists scores were similar between the two groups. On CT scans, median percent variation (range) in abdominal wall muscle volume was significantly greater in the OPN group: -1.03% (-31.4-1.5) vs-0.39% (-5.2-1.8) (P=0.006). The median extent of flank bulge on CT scans (range) was also greater in the OPN group: 0.75 cm (-1.9-7.6) vs 0 cm (-2.7-2.8) (P=0.0004). The OPN group was also more symptomatic, including paresthesia 48% vs 8% (P=0.0053); numbness 44% vs 0% (P=0.002); and flank bulge 57% vs 12% (P=0.007).

CONCLUSIONS

Minimally invasive partial nephrectomy has lesser deleterious impact on flank muscle volume compared with OPN with fewer symptoms of flank bulge, paresthesia, and numbness.

Trends in incidence, mortality, and survival for kidney cancer in Canada, 1986-2007

Purpose

Kidney cancer is one of the fastest rising cancers worldwide. We aimed to examine the trends in incidence, mortality, and survival for this cancer in Canada.

Methods

Incidence data for kidney cancer for 1986–2010 were from the Canadian Cancer Registry and the National Cancer Incidence Reporting System. These data were only available up to 2007 for the province of Quebec and consequently for the same year nationally, for Canada. Mortality data for 1986–2009 were from the Canadian Vital Statistics Death Database. Changes in age-standardized rates were analyzed by Joinpoint regression. Incidence rates were projected to 2025 using a Nordpred age-period-cohort model. Five-year relative survival ratios (RSR) were analyzed for 2004–2008 and earlier periods.

Results

Between 1986 and 2007, the age-standardized incidence rate (ASIR) per 100,000 rose from 13.4 to 17.9 in males and 7.7 to 10.3 in females. Annual increases in ASIR were greatest for age groups <65 years (males) and ≥65 years (females). The ASIRs increased significantly over time in both sexes for renal cell carcinoma (RCC) but not for other kidney cancer types. RCC rates are projected to increase until at least 2025. Mortality rates decreased only slightly in each sex since 1986 (0.4 %/year in males; 0.8 %/year in females). The 5-year RSR for kidney cancer was 68 % but differed largely by morphology and age, and has increased slightly over time.

Conclusions

The incidence rate of kidney cancer in Canada has risen since at least 1986, led largely by RCC. Increasing detection of incidental tumors, and growing obesity and hypertension rates are possible factors associated with this increase. Greater prevention of modifiable risk factors for kidney cancer is needed.

Solid renal masses: what the numbers tell us

OBJECTIVE

Solid renal masses are most often incidentally detected at imaging as small (≤ 4 cm) localized lesions. These lesions comprise a wide spectrum of benign and malignant histologic subtypes, but are largely treated with surgical resection given the limited ability of imaging to differentiate among them with consistency and high accuracy. Numerous studies have thus examined the ability of CT and MRI techniques to separate benign lesions from malignancies and to predict renal cancer histologic grade and subtype. This article synthesizes the evidence regarding renal mass characterization at CT and MRI, provides diagnostic algorithms for evidence-based practice, and highlights areas of further research needed to drive imaging-based management of renal masses.

CONCLUSION

Despite extensive study of morphologic and quantitative criteria at conventional imaging, no CT or MRI techniques can reliably distinguish solid benign tumors, such as oncocytoma and lipid-poor angiomyolipoma, from malignant renal tumors. Larger studies are required to validate recently developed techniques, such as diffusion-weighted imaging. Evidence-based practice includes MRI to assess renal lesions in situations where CT is limited and to help guide management in patients who are considered borderline surgical candidates.

Surgical management of renal cell carcinoma

Surgical resection of renal cell carcinoma (RCC) is the benchmark for long-term cure of the disease. Although open or laparoscopic radical nephrectomy is considered the gold standard for stage T1b-T4 tumors, nephron-sparing surgery is the preferred operative modality for small renal masses demonstrating equivalent oncologic efficacy and improved renal function outcomes compared with complete nephrectomy. With the advance of minimally invasive surgery, nephron-sparing procedures can safely be conducted laparoscopically with or without robotic assistance. RCC with intravenous tumor thrombus presents a surgical challenge, but multidisciplinary surgical approaches can provide long-term benefit in these patients. The role of cytoreductive nephrectomy and metastasectomy in patients with metastatic RCC (mRCC) is controversial, but seems to be beneficial for patients in the era of targeted therapy.

Outcomes in patients undergoing nephrectomy for renal cancer on chronic anticoagulation therapy

AIMS

To report our experience on surgical resection of renal tumors for patients with a history of chronic anticoagulation (ACT) or aspirin use.

METHODS

We performed a retrospective analysis of 2473 patients who underwent surgery for renal tumors between 2005 and 2012. Prior to surgery, 172 were on chronic ACT and 695 on aspirin. Multivariable linear and logistic regression models were used to compare transfusion and overall complication rates between patients undergoing renal surgery who were on therapy to patients who were on aspirin and to patients with no therapy.

RESULTS

Compared to no therapy and aspirin patients those on ACT were older (57.3 (IQR 48.4-66.10) vs 63.9, (IQR 57.3-71.5) vs 68.4, (IQR 60.4-73.5); p < 0.001), with a higher percentage having an ASA score of 3 or 4 (42.4 vs 57.9 vs 82.6%; p < 0.001), respectively. ACT patients had a higher 30-day transfusion rate, 22.7% vs 7.6% vs 6.9%, and 90-day complication rate, 17.4% vs 7.2% vs 7.3%, both p < 0.001. The median length of stay differed statistically between groups (p < 0.001), with a modest longer stay in the anticoagulation group (OR 1.11 SE 0.26; p < 0.001). Transfusion and complication rates for patients on therapy undergoing minimally invasive surgery vs open surgery were not statistically different.

CONCLUSIONS

Patients on chronic ACT had higher transfusion and overall complication rates compared to patients on no treatment or on chronic aspirin. These findings did not correlate to clinical differences in length of stay or grade 3-5 complications.

Laparoscopic partial nephrectomy: An experience in 227 cases

OBJECTIVE

To evaluate our long-term experience with laparoscopic partial nephrectomy (LPN) and to review the literature.

MATERIAL AND METHODS

We performed a retrospective chart review, evaluating 227 consecutives laparoscopic partial nephrectomies performed between June 1995 and June 2010. Perioperative were recorded along with clinical a oncological outcomes.

RESULTS

Mean age was 56.4 years (18-87) and clinical stages were T1a, T1b and T2 in 90.74% (206/227), 7.48% (17/227) and 1.76% (4/227), respectively. Median blood loss was 250 mL (10-1800). The mean operative time was 108.42 minutes (30-240) and median warm ischemia time was 25 minutes (10-60). The intraoperative complication rate was 2.64% (6/227), 5 (2.2%) secondary to bleeding. The postoperative complication rate was 5.72% (13/227) and bleeding is also the most frequent in 3% (7/227) of the cases. According to the Clavien classification, 1.32% (3/227), 0.88% (2/227) and 3.52% (8/227) were grade I, II and IIIb, respectively. The mean hospital stay was 3.66 days (1-12). Clear cell carcinoma was the most common histological finding in 74.6% (150 patients). TNM clasification was T1a, T1b y T2 in 90.74% (206/227), 7.48% (17/227) and 1,76% (4/227), respectively. No conversion or mortality was reported. Positive surgical margins were found in 4 patients (2.7%), with no local recurrence after long-term follow-up. At a mean follow up of 27 months, one patient had port site and peritoneal recurrence.

CONCLUSION

Laparoscopic partial nephrectomy is a safe and viable alternative to open partial nephrectomy, providing equivalent oncologic outcomes and comparable morbidity to the traditional approach in experienced centers.

Comparison between laparoscopic and open partial nephrectomy: surgical, oncologic, and functional outcomes

The surgical, oncologic, and functional outcomes were retrospectively compared of laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) for the treatment of renal masses. Between January 2006 and November 2011, 115 LPNs and 97 OPNs were performed. The patients' demographics were matched. Their intraoperative and postoperative data, oncologic and renal function outcomes were compared. Surgical time, renal arterial occlusion time, estimated blood loss, and postoperative hospitalization days were shorter in the LPN group (p < 0.01). The total complications were comparable; however, LPN had a higher intraoperative complication due to 12 subcutaneous emphysemas. The LPN group was followed up with a mean time of 29.3 ± 14.4 months and the OPN group with a mean time of 31.2 ± 12.6 months. All patients survived and no distant relapse or metastasis were observed. Kaplan-Meier estimates of 60-month local recurrence-free survival were comparable with 92.4% after LPN and 93.8% after OPN, respectively (p = 0.57). The reduction of glomerular filtration rate was more obvious after LPN at the 3-month follow-up (p < 0.01), but similar between the two groups at the 30.2-month follow-up. LPN provides similar results in oncologic and functional outcomes when compared to OPN. Long-term observations are still required to the oncologic and function outcomes.

Trends and variations in utilization of nephron-sparing procedures for stage I kidney cancer in the United States

PURPOSE

The incidental detection of early-stage kidney tumors is increasing in the United States. Nephron-sparing approaches (NS) to managing these tumors are equivalent to radical nephrectomy (RN) in oncologic outcomes and have a decreased impact on renal function. Our objective was to evaluate trends in the use of NS over the past decade and the socioeconomic factors associated with its use.

METHODS

The National Cancer Database was queried to identify patients with stage I kidney cancer between 2000 and 2008. Patients were classified by the type of surgery as NS (local destruction and local excision) or RN. Patients were further categorized by age, race, insurance status, and income. Log-binomial regression was used to estimate prevalence ratios (PR) for the proportion of NS to RN according to demographic and socioeconomic characteristics.

RESULTS

From 2000 to 2008, there were 142,194 cases of kidney cancer reported to the NCDB. In these cases, 43,034 (30.3 %) patients had NS, and 86,431 (60.78 %) patients had RN. The prevalence of NS increased 10 % per year (PR = 1.10, p < 0.0001)-from 20.0 % in 2000 to 45.1 % in 2008. Older age, lower income, Black race, Hispanic ethnicity, and lack of health insurance were associated with a decreased prevalence of NS.

CONCLUSIONS

NS as a treatment for stage I kidney cancer has increased steadily since 2000. Age, racial, and socioeconomic differences may exist in the utilization of NS. Additional analyses, with patient level data, are required to address the independent significance of these variables in an effort to develop strategies to mitigate these potential disparities.

Partial nephrectomy versus radical nephrectomy for non-metastatic pathological T3a renal cell carcinoma: a multi-institutional comparative analysis

OBJECTIVES

To compare the recurrence-free survival of partial nephrectomy and radical nephrectomy in patients with non-metastatic pathological T3a renal cell carcinoma.

METHODS

We reviewed the records of 3567 patients who had undergone a nephrectomy for renal cell carcinoma at five institutions in Korea from January 2000 to December 2010. The clinical data of 45 patients with pathological T3a renal cell carcinoma in the partial nephrectomy group were compared with 298 patients with pathological T3a renal cell carcinoma in the radical nephrectomy group. The effects of surgical methods on recurrence-free survival were assessed by a multivariate Cox proportional hazard analysis. All comparisons were repeated in subgroup analysis on 63 clinical T1a patients with tumors ≤4 cm.

RESULTS

During a median 43-month follow-up period, disease recurrence occurred in two patients (4.4%) in the partial nephrectomy group, and 94 patients (31.5%) in the radical nephrectomy group. The results from a multivariate model showed that radical nephrectomy was a significant predictor of recurrence. However, in subgroup analysis that included 63 clinical T1a pathological T3a patients, the recurrence-free survival rates were not significantly different between the two cohorts. The renal function was significantly better preserved in the partial nephrectomy cohort than in the radical nephrectomy cohort.

CONCLUSIONS

Partial nephrectomy provides similar recurrence-free survival outcomes compared with radical nephrectomy in patients with clinical T1a pathological T3a renal cell carcinoma. However, there seems to be a higher risk of recurrence for large pathological T3a tumors treated by radical nephrectomy compared with small tumors treated by partial nephrectomy. Thus, large tumors with the same pathological T3a renal cell carcinoma grade could have hidden aggressive features.

Robotics in uro-oncologic surgery

In urology, the main use for the robotic technique has been in radical prostatectomy for prostate cancer. Robotic surgery for other organs, such as the kidneys and bladder, has been less explored. However, partial nephrectomy or radical nephroureterectomy can be difficult for inexperienced laparoscopic surgeons. The advent of the da Vinci robot, with multijointed endowristed instruments and stereoscopic vision, decreases the technical difficulty of intracorporeal suturing and improves the reconstructive steps. The objective of this article is to offer an overview of all robotic procedures recently developed in the field of urology. We evaluate the feasibility of these procedures and their potential advantages and disadvantages. We also describe perioperative, postoperative, and oncologic outcomes of robot-assisted surgery as well as perform a comparison with open and laparoscopic techniques. Comparative data and an adequate follow-up are needed to demonstrate equivalent oncologic outcomes in comparison with traditional open or laparoscopic procedures.

Imaging-guided radiofrequency ablation of cystic renal neoplasms

OBJECTIVE

The purpose of this article is to determine whether percutaneous radiofrequency ablation (RFA) is effective and safe for the treatment of cystic renal neoplasms.

MATERIALS AND METHODS

This is a retrospective review of imaging-guided RFA of Bosniak III and IV cysts from one institution. Thirty-eight subjects (19 men and 19 women; mean age, 71 years; age range, 46-95 years) underwent RFA of 40 cystic neoplasms (Bosniak III, n = 25; Bosniak IV, n = 15). Percutaneous biopsy was performed in 90% (36/40) of lesions. For patients with imaging follow-up of at least 1 year (n = 21), the mean duration of surveillance was 2.8 years (range, 1-6.5 years). The electronic medical record was reviewed for complications related to the procedure. Estimated glomerular filtration rate (GFR) was measured before RFA and at the last follow-up visit more than 6 months after the RFA session.

RESULTS

According to percutaneous biopsy, 61.1% (22/36) of lesions were malignant, and 38.9% (14/36) of biopsies were inconclusive. There was no local tumor progression, and no subjects developed metastatic disease. One subject developed a new solid renal mass during the course of follow-up. Minor complications occurred in 5.3% (2/38) of ablations and included dysuria and mild hydronephrosis related to a blood clot in the ureter. There was one major complication (2.6%), a case of flash pulmonary edema. On average, estimated GFR decreased by 2.5 mL/min/1.73 m(2).

CONCLUSION

Imaging-guided RFA is an effective and safe treatment of Bosniak III and IV cystic renal neoplasms with outcomes comparable to those of surgical therapies.

Small renal masses: surgery or surveillance

The incidence of kidney cancer has been rising over the past two decades, especially in cases in which the disease is localized and small in size (<4 cm). This rise is mainly due to the widespread use of routine abdominal imaging such as ultrasonography, computed tomography, and magnetic resonance imaging. Early detection was initially heralded as an opportunity to cure an otherwise lethal disease. However, despite increasing rates of renal surgery in parallel to this trend, mortality rates from renal cell carcinoma have remained relatively unchanged. Moreover, data suggest that a substantial proportion of small renal masses are benign. As a result, the management of small renal masses has continued to evolve along two basic themes: it has become less radical and less invasive. These shifts are in part a reflection of an improved understanding that the biology of incidentally discovered renal cell carcinoma may be more indolent than previously thought. However, not all small renal masses are indolent, and de novo metastatic disease can develop at the initial presentation. Therefore, it is with this background of clinical uncertainty and biological heterogeneity that clinicians must interpret the benefits and disadvantages of various clinical approaches to small renal masses.

Robotic partial nephrectomy: current technique and outcomes

Over the past decade, management of the T1 renal mass has focused on nephron-sparing surgery. Robotic partial nephrectomy has played an increasing role in the technique of preserving renal function by decreasing warm ischemia time, as well as optimizing outcomes of hemorrhage and fistula. Robot-assisted partial nephrectomy is designed to provide a minimally-invasive nephron-sparing surgical option utilizing reconstructive capability, decreasing intracorporeal suturing time, technical feasibility and safety. Ultimately, its benefits are resulting in its dissemination across institutions. Articulated instrumentation and three-dimensional vision facilitate resection, collecting system reconstruction and renorrhaphy, leading to decreased warm ischemia time while preserving oncological outcomes. The aim of the present review was to present our surgical sequence and technique, as well as review the current status of robot-assisted partial nephrectomy.

Zero ischemia laparoscopic partial thulium laser nephrectomy

BACKGROUND AND PURPOSE

Laser technology presents a promising alternative to achieve tumor excision and renal hemostasis with or without hilar occlusion, yet its use in partial nephrectomy has not been significantly evaluated. We prospectively evaluated the thulium:yttrium-aluminum-garnet laser in laparoscopic partial nephrectomy (LPN) in our institution over a 1-year period.

PATIENTS AND METHODS

We used the thulium laser with a wavelength of 2013 nm in the infrared spectrum. Data were recorded prospectively. Tumor size, preoperative aspects and dimensions used for an anatomical classification (PADUA) score, operative time, warm ischemia time (WIT), and perioperative and postoperative morbidity were recorded. Blood loss, preoperative and postoperative creatinine level, and estimated glomerular filtration rate (eGFR) were also collected.

RESULTS

A total of 15 patients underwent consecutive LPN. The mean tumour diameter was 2.85 (1.5-4). The mean PADUA score was 6.8 (6-9). The mean total operative time was 168 minutes (128-306 min). Mean blood loss was 341 mL (0-800 mL). Date of discharge was 3.2 days postoperatively (2-8 days). The renal vessels were not clamped, resulting in a WIT of 0 minutes in all cases. There was no statistical significant increase in serum creatinine level or decrease in eGFR postoperatively. Histologically, the majority of lesions (13/15 patients) were renal-cell carcinoma stage pT1a. In all cases, base margins had negative results for tumor.

CONCLUSION

The 2013-nm thulium laser system offers excellent hemostasis and precise resection capability of the renal cortex during LPN of small partially exophytic renal tumors. Our series showed excellent perioperative functional and pathologic outcomes, including minimal blood loss, zero ischemia, negative tumor margins, and preservation of renal function.

Impact of the length of time between diagnosis and surgical removal of urologic neoplasms on survival

OBJECTIVE

Our aim was to assess the effect of surgical wait time on the survival of patients with urological neoplasms, including prostate, bladder, penile, and testicular cancers and upper tract tumours (UTUC).

MATERIALS AND METHODS

Current, relevant studies were identified from the literature. Keywords used for article retrieval were as follows: delay; surgery; prostate cancer; urothelial carcinoma; renal cell carcinoma; testicular cancer; bladder; renal pelvis; ureter; and survival.

RESULTS

Regarding the length of surgical wait time, it does not matter in cases of incidental T1a renal cell carcinomas. In other cases of renal cell carcinomas, surgery should be considered within <1 month; it is of crucial importance in bladder cancer and should be <1 month for a TURBT in cases of non-muscle-invasive bladder cancer and <1 month for a radical cystectomy in cases of muscle-invasive bladder cancer; it is important in invasive UTUC and should be <1 month for a radical nephroureterectomy; it is not crucial in cases of low-risk prostate cancer. In any other case, radical prostatectomy should be considered within <2 months; it is important in testicular cancer and should be fewer than 10 days for an orchiectomy.

CONCLUSION

Prolonged surgical wait times have an impact on the overall quality of life and anxiety of the patient. Extending the wait time beyond a given threshold can also have a negative impact on the patient's clinical outcomes, but this threshold differs between urological neoplasms.

Treatment options for renal cell carcinoma in renal allografts: a case series from a single institution

Renal cell carcinoma (RCC) is more common in renal transplant and dialysis patients than the general population. However, RCC in transplanted kidneys is rare, and treatment has previously consisted of nephrectomy with a return to dialysis. There has been recent interest in nephron-sparing procedures as a treatment option for RCC in allograft kidneys in an effort to retain allograft function. Four patients with RCC in allograft kidneys were treated with nephrectomy, partial nephrectomy, or radiofrequency ablation. All of the patients are without evidence of recurrence of RCC after treatment. We found nephron-sparing procedures to be reasonable initial options in managing incidental RCCs diagnosed in functioning allografts to maintain an improved quality of life and avoid immediate dialysis compared with radical nephrectomy of a functioning allograft. However, in non-functioning renal allografts, radical nephrectomy may allow for a higher chance of cure without the loss of transplant function. Consequently, radical nephrectomy should be utilized whenever the allograft is non-functioning and the patient's surgical risk is not prohibitive.

Tolerance of the human kidney to isolated controlled ischemia

Tolerance of the human kidney to ischemia is controversial. Here, we prospectively studied the renal response to clamp ischemia and reperfusion in humans, including changes in putative biomarkers of AKI. We performed renal biopsies before, during, and after surgically induced renal clamp ischemia in 40 patients undergoing partial nephrectomy. Ischemia duration was >30 minutes in 82.5% of patients. There was a mild, transient increase in serum creatinine, but serum cystatin C remained stable. Renal functional changes did not correlate with ischemia duration. Renal structural changes were much less severe than observed in animal models that used similar durations of ischemia. Other biomarkers were only mildly elevated and did not correlate with renal function or ischemia duration. In summary, these data suggest that human kidneys can safely tolerate 30-60 minutes of controlled clamp ischemia with only mild structural changes and no acute functional loss.

Risk prediction in the management of small renal masses

PURPOSE OF REVIEW

Small renal masses (SRMs) are frequently encountered due to the ubiquitous use of abdominal cross-sectional imaging. Enhanced risk prediction in the management of SRMs would allow for a more informed decision of which, if any, patients would benefit from the available intervention modalities.

RECENT FINDINGS

Data suggest that a substantial proportion of SRMs are benign and that a significant proportion demonstrate indolent clinical behavior, leading to increased implementation of active surveillance strategies. Extirpative treatment of SRMs may be associated with worse outcomes, particularly in the elderly and infirm. Patient characteristics, including advanced age and comorbidity, and tumor anatomy are being increasingly recognized as having significant prognostic importance in terms of which type of treatment to offer. Further, a recent renewed interest in renal mass biopsy for risk stratification in SRMs has occurred as tumor size, radiographic characteristics, and growth kinetics are limited in their predictive capacity.

SUMMARY

Within the last decade, the reference standard treatment of SRMs evolved from radical nephrectomy to nephron-sparing approaches. This evolution continues, as we learn more about the complex interplay between patient and tumor characteristics and, as outcomes data mature, to ablative therapies and active surveillance.

Near-infrared fluorescence imaging to facilitate super-selective arterial clamping during zero-ischaemia robotic partial nephrectomy

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: There is concern that warm ischaemia time during partial nephrectomy may have an adverse impact on postoperative renal function. As a result, there is increased interest in developing a safe and effective method for performing non-ischaemic partial nephrectomy. Several novel approaches have recently been described. We present our initial experience performing zero-ischaemia partial nephrectomy using near-infrared fluorescence imaging to facilitate super-selective arterial clamping. We report the operative and early postoperative outcomes from such cases as compared with a matched cohort of patients undergoing traditional partial nephrectomy with clamping of the main renal artery. We show that this technique is both safe and effective and may lead to improved renal preservation at short-term follow-up.

OBJECTIVE

To describe a novel technique of eliminating renal ischaemia during robotic partial nephrectomy (RPN) using near-infrared fluorescence (NIRF) imaging.

PATIENTS AND METHODS

Over an 8-month period (March 2011 to November 2011), 34 patients were considered for zero-ischaemia RPN using the da Vinci NIRF system. Targeted tertiary/higher-order tumour-specific branches were controlled with robotic bulldog(s) or neurosurgical aneurysm micro-bulldog(s). Indocyanine green dye was given, and NIRF imaging used to confirm super-selective ischaemia, defined as darkened tumour/peri-tumour area with green fluorescence of remaining kidney. Matched pair analysis was performed by matching each patient undergoing zero-ischaemia RPN (n = 27) to a previous conventional RPN (n = 27) performed by the same surgeon.

RESULTS

Of 34 patients, 27 (79.4%) underwent successful zero-ischaemia RPN; seven (20.6%) required conversion to main renal artery clamping (ischaemia time <30 min) for the following reasons: persistent tumour fluorescence after clamping indicating inadequate tumoral devascularization (n = 5), and parenchymal bleeding during RPN (n = 2). Matched-pair analysis showed comparable outcomes between cohorts, except for longer operating time (256 vs 212 min, P = 0.02) and superior kidney function (reduction of estimated glomerular filtration rate (-1.8% vs -14.9%, P = 0.03) in the zero-ischaemia cohort. All surgical margins were negative.

CONCLUSIONS

In this pilot study, we show that zero-ischaemia RPN with NIRF is a safe alternative to conventional RPN with main renal artery clamping. Eliminating global ischaemia may improve functional outcomes at short-term follow-up.

Positron emission tomography/computed tomography identification of clear cell renal cell carcinoma: results from the REDECT trial

PURPOSE

A clinical study to characterize renal masses with positron emission tomography/computed tomography (PET/CT) was undertaken.

PATIENTS AND METHODS

This was an open-label multicenter study of iodine-124 ((124)I) -girentuximab PET/CT in patients with renal masses who were scheduled for resection. PET/CT and contrast-enhanced CT (CECT) of the abdomen were performed 2 to 6 days after intravenous (124)I-girentuximab administration and before resection of the renal mass(es). Images were interpreted centrally by three blinded readers for each imaging modality. Tumor histology was determined by a blinded central pathologist. The primary end points-average sensitivity and specificity for clear cell renal cell carcinoma (ccRCC)-were compared between the two modalities. Agreement between and within readers was assessed.

RESULTS

(124)I-girentuximab was well tolerated. In all, 195 patients had complete data sets (histopathologic diagnosis and PET/CT and CECT results) available. The average sensitivity was 86.2% (95% CI, 75.3% to 97.1%) for PET/CT and 75.5% (95% CI, 62.6% to 88.4%) for CECT (P = .023). The average specificity was 85.9% (95% CI, 69.4% to 99.9%) for PET/CT and 46.8% (95% CI, 18.8% to 74.7%) for CECT (P = .005). Inter-reader agreement was high (κ range, 0.87 to 0.92 for PET/CT; 0.67 to 0.76 for CECT), as was intrareader agreement (range, 87% to 100% for PET/CT; 73.7% to 91.3% for CECT).

CONCLUSION

This study represents (to the best of our knowledge) the first clinical validation of a molecular imaging biomarker for malignancy. (124)I-girentuximab PET/CT can accurately and noninvasively identify ccRCC, with potential utility for designing best management approaches for patients with renal masses.

"Trifecta" in partial nephrectomy

PURPOSE

We introduce the concept of trifecta outcomes during robotic/laparoscopic partial nephrectomy, in which the 3 key outcomes of negative cancer margin, minimal renal functional decrease and no urological complications are simultaneously realized. We report serial trifecta outcomes in patients treated with robotic/laparoscopic partial nephrectomy for tumor in a 12-year period.

MATERIALS AND METHODS

A total of 534 patients had complete data available and were retrospectively divided into 4 chronologic eras, including the discovery era--139 from September 1999 to December 2003, conventional hilar clamping era--213 from January 2004 to December 2006, early unclamping era--104 from January 2007 to November 2008 and anatomical zero ischemia era--78 from March 2010 to October 2011. Renal functional decrease was defined as a greater than 10% reduction in the actual vs volume predicted postoperative estimated glomerular filtration rate.

RESULTS

Across the 4 eras tumors trended toward larger size (2.9, 2.8, 3.1 and 3.3 cm, p = 0.08) and yet the estimated percent of kidney preserved was similar (89%, 90%, 90% and 88%, respectively, p = 0.3). Recent eras had increasingly complex tumors that were more often 4 cm or greater (p = 0.03), centrally located (p <0.009) or hilar (p <0.0001). Nevertheless, with significant technical refinement warm ischemia time decreased serially (36, 32, 15 and 0 minutes, respectively, p <0.0001). Renal functional outcomes were superior in recent eras with fewer patients experiencing a decrease (p <0.0001). Uniquely, actual estimated glomerular filtration rate outcomes exceeded volume predicted estimated glomerular filtration rate outcomes only in the zero ischemia cohort in regard to other eras (-9.5%, -11%, -0.9% and 4.2%, respectively, p <0.001). Positive cancer margins were uniformly low at less than 1%. Urological complications trended lower in recent eras (p = 0.01). Trifecta outcomes occurred more commonly in recent eras (45%, 44%, 62% and 68%, respectively, p = 0.0002).

CONCLUSIONS

Trifecta should be a routine goal during partial nephrectomy. Despite increasing tumor complexity, trifecta outcomes of robotic/laparoscopic partial nephrectomy improved significantly in the last decade.