Outcomes of synchronous and metachronous bilateral small renal masses (< 4 cm): a population-based cohort study

Surgical Management of Synchronous, Bilateral Renal Masses: A 1-decade Referral Center Experience

BACKGROUND

Management and decision-making in patients with bilateral renal masses are controversial.

OBJECTIVE

To report our experience of surgical management in patients with bilateral renal masses undergoing surgery at a high-volume center.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively collected data from patients treated with partial nephrectomy (PN) or radical nephrectomy for bilateral renal masses at a single referral institution between June 2008 and June 2019. Patient- and tumor-related features, timing (one vs two stage), and surgical approach (open vs robotic) were analyzed.

SURGICAL PROCEDURE

A one- versus two-stage strategy was adopted according to the opportunity to perform at least one PN using a clampless or selective-clamping approach, in order to avoid acute kidney injury.

MEASUREMENTS

Operative time, warm ischemia time, and intra- and postoperative complications were recorded. Histopathological results and tumor histology were assessed.

RESULTS AND LIMITATIONS

Overall, 41 patients were included. The median age was 67 yr and the median preoperative estimated glomerular filtration rate (eGFR) was 84 ml/min/1.73 m². The median Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 8 (interquartile range [IQR] 7-8) for both sides. In 17 (42%) patients, a simultaneous approach was chosen, with a pure robotic approach in 11/17 cases, while among the 24 (58.6%) patients treated with a two-stage strategy, 15 (62.5%) were treated with a robotic approach on both sides. Intraoperative complications and postoperative major (CDC ≥3) complications were recorded in 7.3% and 4.9% of cases, respectively. The overall positive surgical margins rate was 2.4%. At a median follow-up of 42 (IQR 18-59) mo, the median eGFR was 73 (IQR 64-80) ml/min/1.73 m², while disease-free survival and cancer-specific mortality were 90.2% and 7.3%, respectively.

CONCLUSIONS

Our experience underlines that both simultaneous and staged surgical treatment of patients with bilateral renal masses are feasible and safe if grounded on proper patient selection.

PATIENT SUMMARY

Management of patients with bilateral renal masses is challenging, given the heterogeneity of clinical scenarios and the need to optimize the timing of treatment to achieve maximal functional preservation while ensuring oncological efficacy.

Evaluation of functional outcome of bilateral kidney tumors after sequential surgery

Background

There are limited data concerning patients treated with sequential bilateral kidney surgery. Current guidelines still lack an optimal surgical sequencing approach. We evaluated renal functional outcomes after sequential partial nephrectomy (PN) and radical nephrectomy (RN) in patients with bilateral renal cell carcinoma (RCC).

Methods

A propensity score matched cohort of 267 patients (synchronous bilateral RCCs, N = 44 [88 lesions]; metachronous bilateral, N = 45 [90 lesions]; unilateral, N = 178) from two tertiary institutions were retrospectively analyzed. Synchronous bilateral RCCs were defined as diagnosis concomitantly or within 3 months of former tumor. Renal functional outcomes were defined as estimated glomerular filtration rate (eGFR) changes and de novo chronic kidney disease (CKD, stage ≥3) after surgery. Renal functional outcomes and clinical factors predicting de novo CKD were assessed using descriptive statistics and Cox regression analysis.

Results

In subgroup of bilateral RCCs, patients underwent sequential PN (N = 48), PN followed by RN (N = 8), or RN followed by PN (N = 25). Final postoperative estimated glomerular filtration rates (eGFRs) were 79.4, 41.4, and 61.2 ml/minute/1.73 m2, respectively (p = 0.003). There were significant differences in eGFR decline from baseline and de novo chronic kidney disease (CKD stage ≥ III) among groups, with PN followed by RN group showing the worst functional outcomes (all p <  0.05). Moreover, sequential PN subgroup in bilateral RCC showed significantly higher rate of de novo CKD than unilateral RCC group (13.8% vs. 6.9%, p = 0.016). On multivariate analysis, hypertension (p = 0.010) and surgery sequence (PN followed by RN, p <  0.001) were significant predictors of de novo CKD.

Conclusions

The surgery sequence should be prudently determined in bilateral renal tumors. PN followed by RN showed a negative impact on renal functional preservation. Nephron-sparing surgery should be considered for all amenable bilateral RCCs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08324-3.

Metastasectomy of Sequential Asynchronous Metastatic Renal Cell Carcinoma to the Pancreas, Thyroid, Skin, Contralateral Kidney, and Lung with Cumulative Survival Beyond 10 Years: A Case Report and Clinicopathologic Review

Patient: Female, 46-year-old

Final Diagnosis: Metastasis of renal clear cell carcinoma

Symptoms: Renal carcinoma

Medication:—

Clinical Procedure: —

Specialty: Urology

Active surveillance of small renal masses

Most renal masses incidentally detected by cross-sectional images are benign, being mainly cysts, and if they are malignant, they are indolent in nature with limited metastatic potential. Enhanced renal masses less than 4 cm in size are known as small renal masses (SRMs), and their growth rate (GR) and the possibility of developing metastasis are extremely low. Delayed intervention of SRMs by closed and routine imaging follow-up known as active surveillance (AS) is now an option according to urological guidelines. Radiologists have a key position in AS management of SRMs even unifocal and multifocal (sporadic or associated with genetic syndromes) and also in the follow-up of complex renal cysts by Bosniak cyst classification system. Radiologists play a key role in the AS of both unifocal and multifocal (sporadic or associated with genetic syndromes) SRMs as well as in the follow-up of complex renal cysts using the Bosniak cyst classification system. Indeed, radiologists must determine which patients with SRMs or complex renal cysts can be included in AS, establish the follow-up radiological test algorithm to be used in different scenarios, perform measurements in follow-up tests, and decide when AS should be discontinued. The purpose of this article is to review the indications and management of AS in SRMs, especially focused on specific scenarios, such as complex renal cysts and multifocal renal tumors (sporadic or hereditary). In this work, the authors aimed to provide a thorough review of imaging in the context of active surveillance of renal masses.

Synchronous Bilateral RCC Is Associated With Poor Recurrence-Free Survival Compared With Unilateral RCC: A Single-Center Study With Propensity Score Matching Analysis

BACKGROUND

Understanding the tumorigenesis of bilateral cancers occurring in paired organs is essential for treatment planning and follow-up strategies. To the best of our knowledge, only a few studies compared the survival outcomes in patients with unilateral and bilateral renal cell carcinoma (RCC). We aimed to evaluate the survival outcomes of these patients after surgery and perform a further comparison of synchronous and metachronous bilateral RCCs.

MATERIALS AND METHODS

We analyzed clinical data from a total of 2169 patients (98.0%) diagnosed with unilateral RCC and 44 patients (2.0%) diagnosed with bilateral RCC including 22 (50.0%) with synchronous (diagnosed concomitantly or within 3 months of the former tumor) and 22 (50.0%) with metachronous RCC at our institution. Comparative analysis of unilateral and bilateral RCC groups was conducted using propensity score matching analysis. Subgroup analysis of bilateral RCC including synchronous and metachronous RCCs was also performed.

RESULTS

Kaplan-Meier survival analysis showed a significantly decreased 5-year recurrence-free survival (RFS; 82.6% vs. 94.3%; log rank test, P = .045) in the bilateral RCC group compared with the unilateral group. In subgroup analysis, the metachronous RCC group showed significantly smaller mean pathologic tumor size (P = .011), and more favorable pathologic T stage (P = .036) compared with the synchronous RCC group. Kaplan-Meier survival analysis showed significantly decreased 5-year RFS in synchronous RCC compared with metachronous RCC (74.7% vs. 92.9%; log rank test, P = .028).

CONCLUSION

The bilateral RCC group showed significantly decreased 5-year RFS compared with the unilateral RCC group. Importantly, the synchronous RCC group manifested more adverse features than the metachronous group.