American Confederation of Urology (CAU) experience in minimally invasive partial nephrectomy

Does a Positive Surgical Margin After Nephron Sparing Surgery Affect Oncological Outcome in Renal Cell Carcinoma? A Systematic Review and Meta-analysis

We systematically evaluated the impact of positive surgical margins (PSM) on oncological outcomes after partial nephrectomy for renal cell carcinoma. Forty-two studies comprising 101,153 subjects were included and five distinct meta-analyses were performed. PSM was associated with increased risk of local recurrence (hazard ratio (HR) 6.11-high certainty), metastasis (HR 3.29-moderate certainty), overall relapse (HR 2.25-high certainty), overall mortality (HR 1.30-moderate certainty), and may be associated with increased cancer-specific mortality (HR 1.91-low certainty). Patients with PSM should be counseled for the possibility of additional surgery, novel adjuvant therapies, and more rigorous surveillance.

Hemopatch® as a Hemostatic Agent is Safe in Partial Nephrectomy: A Large, Single-Surgeon Retrospective Evaluation

Introduction

Partial nephrectomy (PN) has evolved into the surgical standard of care for localized renal lesions. Hemostatic agents (HA) support the surgeon in achieving local hemostasis during PN. We previously reported initial results with the HA Hemopatch^® in PN. We now report our experiences with Hemopatch^® in a larger and more challenging single-surgeon PN cohort.

Methods

Our study included 45 patients who underwent PN due to suspicious renal lesions between December 2013 and March 2018. All surgeries were performed by a single surgeon using the HA Hemopatch^®. Preoperative, intraoperative, and postoperative parameters were assessed.

Results

Preoperative median tumor diameter was 27 mm. Median PADUA and RENAL nephrometry scores were 7 and 6, respectively. In 13.3% of the cases an additional HA was applied. Intraoperative and postoperative bleeding occurred in 2.2% and 8.9%, respectively. Median total blood loss was 200 ml. Urgent pedicle clamping due to bleeding was necessary in 2 (4.4%) patients. The transfusion rate was 8.9%. There were no conversions.

Conclusion

We confirmed our initial results demonstrating feasibility and reliability of Hemopatch^® during PN. Notably, the cohort consists of selected patients. Prospective randomized studies are needed for comparison of different types of HA with regard to perioperative outcome.

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.

Analyzing National Incidences and Predictors of Open Conversion During Minimally Invasive Partial Nephrectomy for cT1 Renal Masses

Objectives: To analyze predictors of open conversion during minimally invasive partial nephrectomy (MIPN) for cT1 renal masses. Methods: The National Cancer Database (NCDB) was investigated for kidney cancer patients who underwent partial nephrectomy (PN) between 2010 and 2015. Patients who underwent MIPN were stratified into converted and nonconverted groups. Sociodemographics, facility characteristics, and surgical outcomes were compared between the two groups, and multivariate logistic regression model was fitted to identify independent predictors of open conversion. Results: In total, 54,246 patients underwent PN for kidney cancer during the 6-year period. Of those, 18,994 (35%) were open partial nephrectomies (OPNs) and 35,252 (64%) were MIPN. Overall, 1010 (2.87%) of MIPNs were converted to OPN. There was an increasing utilization of MIPN from 50.35% in 2010 to 74.73% in 2015. Patients who had open conversion had more 30-day readmissions (5.95% vs 3.31%, p < 0.01). On multivariate analysis; high-volume facility (>30 MIPNs/year), year of surgery (2015 vs 2010), and robotic approach predicted a lower likelihood of conversion (odds ratio [OR] 0.52, confidence interval [CI] 0.44-0.62; OR 0.59, CI 0.47-0.73; and OR 0.31, CI 0.27-0.35; respectively, p < 0.001 for all). Conversely, Medicaid (vs private insurance; OR 1.75, CI 1.39-2.19, p < 0.001) and male sex (OR 1.26, CI 1.11-1.44, p < 0.001) were independent predictors of conversion. Conclusions: Open conversion in MIPN occurred in 2.87% of cases. There was an increasing utilization of MIPN associated with decreased conversion rates. Higher volume hospitals and progressing year of surgery were associated with less likelihood of conversion.

Use of Contrast Ultrasound for Renal Mass Evaluation

An introduction to the expanding modality of contrast-enhanced ultrasound is provided, along with basics on contrast agents and technique. The contrast ultrasound findings of multiple renal tumors are reviewed with examples, including clear cell renal cell carcinoma, papillary renal cell carcinoma, chromophobe renal cell carcinoma, other rare renal cell carcinoma subtypes, oncocytoma, upper tract urothelial carcinoma, lymphoma, and angiomyolipoma, followed also by brief discussions of renal infections and pseudolesions.

Imaging for the diagnosis and response assessment of renal tumours

PURPOSE

Imaging plays a key role throughout the renal cell carcinoma (RCC) patient pathway, from diagnosis and staging of the disease, to the assessment of response to therapy. This review aims to summarise current knowledge with regard to imaging in the RCC patient pathway, highlighting recent advances and challenges.

METHODS

A literature review was performed using Medline. Particular focus was paid to RCC imaging in the diagnosis, staging and response assessment following therapy.

RESULTS

Characterisation of small renal masses (SRM) remains a diagnostic conundrum. Contrast-enhanced ultrasound (CEUS) has been increasingly applied in this field, as have emerging technologies such as multiparametric MRI, radiomics and molecular imaging with 99mtechnetium-sestamibi single photon emission computed tomography/CT. CT remains the first-line modality for staging of locoregional and suspected metastatic disease. Although the staging accuracy of CT is good, limitations in determining nodal status persist. Response assessment following ablative therapies remains challenging, as reduction in tumour size may not occur. The pattern of enhancement on CT may be a more reliable indicator of treatment success. CEUS may also have a role in monitoring response following ablation. Response assessments following anti-angiogenic and immunotherapies in advanced RCC is an evolving field, with a number of alternative response criteria being proposed. Tumour response patterns may vary between different immunotherapy agents and tumour types; thus, future response criteria modifications may be inevitable.

CONCLUSION

The diagnosis and characterisation of SRM and response assessment following targeted therapy for advanced RCC are key challenges which warrant further research.