Elective Nephron Sparing Surgery Decreases Other Cause Mortality Relative to Radical Nephrectomy Only in Specific Subgroups of Patients with Renal Cell Carcinoma

Preoperative risk calculator for the probability of completing nephron sparing for kidney cancer

PURPOSE

In absence of predictive models, preoperative estimation of the probability of completing partial (PN) relative to radical nephrectomy (RN) is invariably inaccurate and subjective. We aimed to develop an evidence-based model to assess objectively the probability of PN completion based on patients' characteristics, tumor's complexity, urologist expertise and surgical approach.

DESIGN, SETTING AND PARTICIPANTS

675 patients treated with PN or RN for cT1-2 cN0 cM0 renal mass by seven surgeons at one single experienced centre from 2000 to 2019.

OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSES

The outcome of the study was PN completion. We used a multivariable logistic regression (MVA) model to investigate predictors of PN completion. We used SPARE score to assess tumor complexity. We used a bootstrap validation to compute the model's predictive accuracy. We investigated the relationship between the outcomes and specific predictors of interest such as tumor's complexity, approach and experience.

RESULTS

Of 675 patients, 360 (53%) were treated with PN vs. 315 (47%) with RN. Smaller tumors [Odds ratio (OR): 0.52, 95%CI 0.44-0.61; P < 0.001], lower SPARE score (OR: 0.67, 95%CI 0.47-0.94; P = 0.02), more experienced surgeons (OR: 1.01, 95%CI 1.00-1.02; P < 0.01), robotic (OR: 10; P < 0.001) and open (OR: 36; P < 0.001) compared to laparoscopic approach resulted associated with higher probability of PN completion. Predictive accuracy of the model was 0.94 (95% CI 0.93-0.95).

CONCLUSIONS

The probability of PN completion can be preoperatively assessed, with optimal accuracy relaying on routinely available clinical information. The proposed model might be useful in preoperative decision-making, patient consensus, or during preoperative counselling.

PATIENT SUMMARY

In patients with a renal mass the probability of completing a partial nephrectomy varies considerably and without a predictive model is invariably inaccurate and subjective. In this study we build-up a risk calculator based on easily available preoperative variables that can predict with optimal accuracy the probability of not removing the entire kidney.

Differences in other-cause mortality in metastatic renal cell carcinoma according to partial vs. radical nephrectomy and age: A propensity score matched study

INTRODUCTION

It is unknown whether the benefit from partial nephrectomy regarding lower other-cause mortality is applicable to older patients with metastatic renal cell carcinoma.

MATERIALS AND METHODS

Using Surveillance Epidemiology and End Results database, patients with metastatic renal cell carcinoma, undergoing partial or radical nephrectomy, were stratified according to age (<60, 60-69, and ≥70 years). After propensity score matching, Kaplan-Meier survival analyses and multivariable Cox regression models were used.

RESULTS

Of 2,390 patients with metastatic renal cell carcinoma, 885 (37%) were aged <60 years, and 90 (10%) underwent partial nephrectomy; 824 (34%) were aged 60-69 years, and 61 (7%) underwent partial nephrectomy; and 681 (29%) were aged ≥70 years, and 64 (9%) underwent partial nephrectomy. After propensity score matching, in patients aged <60 years, partial nephrectomy was associated with lower other-cause mortality (hazard ratio 0.22; p = 0.02); in patients aged 60-69 years, partial nephrectomy was associated with lower other-cause mortality (hazard ratio 0.38; p = 0.03); but not in patients aged ≥70 years.

DISCUSSION

In metastatic renal cell carcinoma, partial nephrectomy is associated with lower other-cause mortality in patients aged <60 years and in patients aged 60-69 years, but not in patients aged ≥70 years. In consequence, consideration of partial nephrectomy might be of great value in younger metastatic renal cell carcinoma patients.

Impact of chronic kidney disease stages on surgical and functional outcomes in robot-assisted partial nephrectomy for localized renal tumors

The influence of chronic kidney disease stage on robot-assisted partial nephrectomy outcomes remains underexplored. This study aimed to assess the impact of chronic kidney disease stage on functional and surgical outcomes of robot-assisted partial nephrectomy and identify preoperative predictors of significant postoperative 1-year renal-function loss (RFL). Clinical data of 408 patients who underwent robot-assisted partial nephrectomy at Yokohama City University Hospital between 2016 and 2023 were retrospectively reviewed. The da Vinci Surgical System was applied in all patients, and outcomes assessed included surgical parameters, postoperative estimated glomerular filtration rate, trifecta and pentafecta achievements, and complications. Significant RFL was defined as estimated glomerular filtration rate reduction ≥ 25% from baseline. Higher chronic kidney disease stages correlated with older age, hypertension, diabetes, and solitary kidneys. Postoperative estimated glomerular filtration rate decline was most pronounced in patients with chronic kidney disease stages 4-5. Although the chronic kidney disease stage did not significantly affect most surgical parameters, pentafecta achievement was higher in patients with chronic kidney disease stage 3 than in those with stages 4-5. Two patients required hemodialysis after robot-assisted partial nephrectomy. Multivariable logistic regression analysis showed that preoperative hemoglobin level and maximum tumor diameter were significant predictive factors for significant RFL. In conclusion, preoperative CKD stage did not influence on surgical outcome except for pentafecta achievement. RAPN may be feasible for patients with CKD stages 4-5 because of no rapid progression to hemodialysis induction and no procedure-related mortality. Preoperative hemoglobin levels and tumor diameter emerged as predictors of significant RFL.

Laparoscopic partial versus radical nephrectomy for localized renal cell carcinoma over 4 cm

PURPOSE

To compare the long-term clinical and oncologic outcomes of laparoscopic partial nephrectomy (LPN) and laparoscopic radical nephrectomy (LRN) in patients with renal cell carcinoma (RCC) > 4 cm.

METHODS

We retrospectively reviewed the records of all patients who underwent LPN or LRN in our department from January 2012 to December 2017. Of the 151 patients who met the study selection criteria, 54 received LPN, and 97 received LRN. After propensity-score matching, 51 matched pairs were further analyzed. Data on patients' surgical data, complications, histologic data, renal function, and survival outcomes were collected and analyzed.

RESULTS

Compared with the LRN group, the LPN group had a longer operative time (135 min vs. 102.5 min, p = 0.001), larger intraoperative bleeding (150 ml vs. 50 ml, p < 0.001), and required longer stays in hospital (8 days vs. 6 days, p < 0.001); however, the level of ECT-GFR was superior at 3, 6, and 12 months (all p < 0.001). Similarly, a greater number of LRN patients developed CKD compared with LPN until postoperative 12 months (58.8% vs. 19.6%, p < 0.001). In patients with preoperative CKD, LPN may delay the progression of the CKD stage and even improve it when compared to LRN treatment. There were no significant differences between the two groups for OS, CSS, MFS, and PFS (p = 0.06, p = 0.30, p = 0.90, p = 0.31, respectively). The surgical method may not be a risk factor for long-term survival prognosis.

CONCLUSION

LPN preserves renal function better than LRN and has the potential value of significantly reducing the risk of postoperative CKD, but the long-term survival prognosis of patients is comparable.

Partial Nephrectomy Drives the Association Between High-volume Centers and Decreased Mortality: A Surveillance, Epidemiology, and End Results-Medicare Analysis

OBJECTIVE

To better understand the association between high-volume surgical kidney cancer centers and decreased mortality. To identify quality metrics that mediate this association.

METHODS

We designed a cohort of 14,044 patients who were diagnosed with kidney cancer between 2004 and 2013 and underwent a partial or radical nephrectomy using SEER-Medicare data. Hospitals were divided into quartiles based on their total nephrectomy volume for the study period. We investigated 6 quality metrics as potential mediators of the association between hospital volume and mortality using a mediation model.

RESULTS

At the highest volume centers, survival was higher at 1-, 3-, 5-, and 10-year time intervals, respectively (91% vs 89%, 80% vs 76%, 70% vs 66%, 45% vs 38%, P < .001) compared to the lowest quartile nephrectomy centers. Receipt of partial nephrectomy for stage ≤T1a tumors explains 52.3% of the total association between hospital nephrectomy volume and mortality. Additionally, patients at the highest-volume centers were more likely to be younger (20% vs 26% 80≤ years old, P < .001), white (82% vs 78%, P < .001), reside in more densely populated counties (≥1 million residents, 62% vs 42%, P > .001), have a shorter mean length of stay (5.03 vs 5.88days, P < .001) when compared to those in the lowest-volume quartile.

CONCLUSION

This analysis of SEER-Medicare data is the first to suggest that partial nephrectomy in the setting of T1a tumors mediates the association between hospital volume and mortality. Quality metrics that reduce mortality should be harnessed to develop more efficient and higher-quality health systems.

The Association of Ischemia Type and Duration with Acute Kidney Injury after Robot-Assisted Partial Nephrectomy

BACKGROUND

Acute kidney injury (AKI) after robot-assisted partial nephrectomy (RAPN) is a robust surrogate for chronic kidney disease. The objective of this study was to evaluate the association of ischemia type and duration during RAPN with postoperative AKI.

MATERIALS AND METHODS

We reviewed all patients who underwent RAPN at our institution since 2011. The ischemia types were warm ischemia (WI), selective artery clamping (SAC), and zero ischemia (ZI). AKI was defined according to the Risk Injury Failure Loss End-Stage (RIFLE) criteria. We calculated ischemia time thresholds for WI and SAC using the Youden and Liu indices. Logistic regression and decision curve analyses were assessed to examine the association with AKI.

RESULTS

Overall, 154 patients met the inclusion criteria. Among all RAPNs, 90 (58.4%), 43 (28.0%), and 21 (13.6%) were performed with WI, SAC, and ZI, respectively. Thirty-three (21.4%) patients experienced postoperative AKI. We extrapolated ischemia time thresholds of 17 min for WI and 29 min for SAC associated with the occurrence of postoperative AKI. Multivariable logistic regression analyses revealed that WIT ≤ 17 min (odds ratio [OR] 0.1, p < 0.001), SAC ≤ 29 min (OR 0.12, p = 0.002), and ZI (OR 0.1, p = 0.035) significantly reduced the risk of postoperative AKI.

CONCLUSIONS

Our results confirm the commonly accepted 20 min threshold for WI time, suggest less than 30 min ischemia time when using SAC, and support a ZI approach if safely performable to reduce the risk of postoperative AKI. Selecting an appropriate ischemia type for patients undergoing RAPN can improve short- and long-term functional kidney outcomes.

Early perioperative outcomes of single-port compared to multi-port robot-assisted laparoscopic partial nephrectomy

Single-port (SP) robot-assisted laparoscopic partial nephrectomy (RAPN) is a promising new technique. The aim of this study was to compare surgical and oncological outcomes of SP-RAPN to the multi-port (MP) surgical platform. This is a retrospective, cohort-based study involving patients undergoing SP-RAPN between 2019 and 2020 at a single institution. Demographic, preoperative, surgical, and postoperative outcomes data were gathered and compared to a 1-to-1 matched MP cohort. A total of 50 SP and 50 matched MP cases were included. Length of surgery and ischemia time were not statistically significant between the two cohorts; however, estimated blood loss (EBL) was significantly lower in the SP group than in the MP (IQR 25-50 vs. IQR 50-100 mL, p = 0.002). No differences were seen in regard to the 30-day readmission rate, surgical margin status, pain scores, and complications between the two approaches. We found no statistically significant differences in positive margins, pain score, length of stay, or readmission rate between matched SP and MP patients. These data support the viability of the SP technique as an alternative to MP-RAPN when in the hands of experienced surgeons.

Predictive characteristics for disease recurrence and overall survival in non-metastatic clinical T1 renal cell carcinoma - results from the National Swedish Kidney Cancer Register

OBJECTIVE

Patients with clinical T1 renal cell carcinoma (cT1RCC) have risks for recurrence and reduced overall survival despite being in the best prognostic group. This study aimed to evaluate the association of different treatments on disease recurrence and overall survival using clinical and pathological characteristics in a nation-wide cT1RCC cohort.

MATERIALS AND METHODS

A total of 4,965 patients, registered in the National Swedish Kidney Cancer Register (NSKCR) between 2005 and 2014, with ≥ 5-years follow-up were identified: 3,040 males and 1,925 females, mean age 65 years. Times to recurrence and overall survival were analyzed with Kaplan-Meier curves, log-rank test, and Cox regression models.

RESULTS

Age, TNM-stage, tumor size, RCC-type, and performed treatment were all associated with disease recurrence. Patients selected for ablative treatments had increased risk for recurrent disease: hazard ratio (HR) = 3.79 [95% confidence interval (CI) = 2.69-5.32]. In multivariate analyses, age, gender, tumor size, RCC-type, N-stage, recurrence and performed treatment were all independently associated with overall survival. Patients with chRCC had a 41% better overall survival (HR = 0.59, 95% CI = 0.44-0.78; p < 0.001) than ccRCC. Patients treated with partial nephrectomy (PN) had an 18% better overall survival (HR = 0.83, 95% CI = 0.71-0.95, p < 0.001) than patients treated with radical nephrectomy.

CONCLUSIONS

Age, gender, T-stage, tumor size, RCC type and treatment modality are all associated with risk of recurrence. Furthermore, age, male gender, tumor size, N-stage and recurrence are associated with reduced overall survival. Patients with chRCC, compared with ccRCC and pRCC patients, and PN compared with RN treated patients, had an advantageous overall survival, indicating a possible survival advantage of nephron sparing treatment.

Estimating Postoperative Renal Function After Surgery for Nonmetastatic Renal Masses: A Systematic Review of Available Prediction Models

CONTEXT

A variety of models predicting postoperative renal function following surgery for nonmetastatic renal tumors have been reported, but their validity and clinical usefulness have not been formally assessed.

OBJECTIVE

To summarize prediction models available for estimation of mid- to long-term (>3 mo) postoperative renal function after partial nephrectomy (PN) or radical nephrectomy (RN) for nonmetastatic renal masses that include only preoperative or modifiable intraoperative variables.

EVIDENCE ACQUISITION

A systematic review of the English-language literature was conducted using the MEDLINE, Embase, and Web of Science databases from January 2000 to March 2022 according to the PRISMA guidelines (PROSPERO ID: CRD42022303492). Risk of bias was assessed according to the Prediction Model Study Risk of Bias Assessment Tool.

EVIDENCE SYNTHESIS

Overall, 21 prediction models from 18 studies were included (nine for PN only; eight for RN only; four for PN or RN). Most studies relied on retrospective patient cohorts and had a high risk of bias and high concern regarding the overall applicability of the proposed model. Patient-, kidney-, surgery-, tumor-, and provider-related factors were included among the predictors in 95%, 86%, 100%, 61%, and 0% of the models, respectively. All but one model included both patient age and preoperative renal function, while only a few took into account patient gender, race, comorbidities, tumor size/complexity, and surgical approach. There was significant heterogeneity in both the model building strategy and the performance metrics reported. Five studies reported external validation of six models, while three assessed their clinical usefulness using decision curve analysis.

CONCLUSIONS

Several models are available for predicting postoperative renal function after kidney cancer surgery. Most of these are not ready for routine clinical practice, while a few have been externally validated and might be of value for patients and clinicians.

PATIENT SUMMARY

We reviewed the tools available for predicting kidney function after partial or total surgical removal of a kidney for nonmetastatic cancer. Most of the models include patient and kidney characteristics such as age, comorbidities, and preoperative kidney function, and a few also include tumor characteristics and intraoperative variables. Some models have been validated by additional research groups and appear promising for improving counseling for patients with nonmetastatic cancer who are candidates for surgery.

Estimated Glomerular Filtration Rate Decline at 1 Year After Minimally Invasive Partial Nephrectomy: A Multimodel Comparison of Predictors

Background

Long-term renal function after partial nephrectomy (PN) is difficult to predict as it is influenced by several modifiable and nonmodifiable variables, often intertwined in complex relations.

Objective

To identify variables influencing long-term renal function after PN and to assess their relative weight.

Design, setting, and participants

A total of 457 patients who underwent either robotic (n = 412) or laparoscopic PN (n = 45) were identified from a multicenter international database.

Outcome measurements and statistical analysis

The 1-yr estimated glomerular filtration rate (eGFR) percentage loss (1YPL), defined as the eGFR percentage change from baseline at 1 yr after surgery, was the outcome endpoint. Predictors evaluated included demographic data, tumor features, and operative and postoperative variables. Bayesian multimodel analysis of covariance was used to build all possible models and compare the fit of each model to the data via model Bayes factors. Bayesian model averaging was used to quantify the support for each predictor via the inclusion Bayes factor (BF_incl). High-dimensional undirected graph estimation was used for network analysis of conditional independence between predictors.

Results and limitations

Several models were found to be plausible for estimation of 1YPL. The best model, comprising postoperative eGFR percentage loss (PPL), sex, ischemia technique, and preoperative eGFR, was 207 times more likely than all the other models regarding relative predictive performance. Its components were part of the top 44 models and were the predictors with the highest BF_incl. The role of cold ischemia, solitary kidney status, surgeon experience, and type of renorraphy was not assessed.

Conclusions

Preoperative eGFR, sex, ischemia technique, and PPL are the best predictors of eGFR percentage loss at 1 yr after minimally invasive PN. Other predictors seem to be irrelevant, as their influence is insignificant or already nested in the effect of these four parameters.

Patient summary

Kidney function at 1 year after partial removal of a kidney depends on sex, the technique used to halt blood flow to the kidney during surgery, and kidney function at baseline and in the early postoperative period.

Parenchymal biopsy in the management of patients with renal cancer

PURPOSE

The role of non-tumour renal biopsy in predicting renal function after surgery for renal cell carcinoma (RCC) is poorly investigated. The aim of the study was to assess the impact of renal parenchymal histology on renal function after radical nephrectomy in a cohort of patients with RCC.

METHODS

This cohort study included 171 patients with RCC submitted to radical nephrectomy between 2006 and 2018. Two biopsy samples from normal parenchyma were collected at nephrectomy and renal parenchyma damage (RPD) was scored on histologic samples according to validated methodology. The outcomes were eGFR after surgery and its reduction > 25% relative to baseline at maximum 12 months' follow-up. Linear and logistic multivariable regression were used, adjusting for age at surgery, presence of hypertension, diabetes, clinical tumour size, time from surgery and basal eGFR.

RESULTS

171 patients were enrolled and RPD was demonstrated in 64 (37%). Patients with RPD had more comorbidities (CCI > 2 in 25 vs. 9%, p < 0.001), in particular hypertension (70 vs. 53%; p = 0.03), diabetes with (5% vs. 0%, p = 0.007) or without (31 vs. 18%; p = 0.007) organ damage, cerebrovascular disease (19 vs. 5%; p = 0.006) and nephropathy (20 vs. 3%; p = 0.0004). At multivariable analyses, RPD was associated with lower eGFR (Est. - 5.48; 95% CI - 9.27: - 1.7; p = 0.005) and with clinically significant reduction of eGFR after surgery (OR 3.06; 95% CI 1.17: 8.49; p = 0.026).

CONCLUSIONS

Presence of RPD in non-tumour renal tissue is an independent predictor of functional impairment in patients with RCC. Such preliminary finding supports the use of parenchyma biopsy during clinical decision making.

The impact of visceral adipose tissue on post -operative renal Function after Radical Nephrectomy for renal cell carcinoma

BACKGROUND

The objective of this study was to evaluate the usefulness of pre-operative visceral (VAT) and subcutaneous adipose tissue (SAT) evaluation in the prediction of Acute Kidney Injury (AKI) and decrease of eGFR at 12 months after radical nephrectomy (RN).

METHODS

We relied on 112 patients who underwent RN between January 2010 and March 2017 at a single institution. Images from the pre-operatory CT scan were analyzed and both SAT and VAT assessments were carried out on a cross-sectional plane. eGFR was measured before surgery, at 7 days, and 12 months after surgery. ROC analysis was used to compare the diagnostic value of BMI, VAT ratio, and abdominal circumference in predicting AKI. Logistic regression models were fitted to predict the new onset of AKI, and the progression from chronic kidney disease (CKD) stage 1-3a to CKD stage 3b or from 3b to 4 at 12 months follow-up. Two logistic regression models were also performed to assess the predictors for AKI and CKD stage progression. The predictive accuracy was quantified using the receiver operating characteristic-derived area under the curve.

RESULTS

Sixty-six patients (58.9%) had AKI after RN. Thirty-five (31.3%) patients were upgraded to CKD IIIb or from CKD stage IIIb to CKD IV. In the ROC analysis, VAT% performed better than the BMI and abdominal circumference (AUC = 0.66 vs 0.49 and 0.54, respectively). At multivariable analyses, VAT reached an independent predictor status for AKI (OR: 1.03) and for CKD stage at 12 months Follow-up (OR: 1.05). Inclusion of VAT% into the multivariable models was associated with the highest accuracy both for AKI (AUC = 0.700 vs 0.570) and CKD stage progression (AUC = 0.848 vs 0.800).

CONCLUSIONS

In patients undergoing RN, preoperative visceral adipose tissue ratio significantly predicts AKI incidence and is significantly predictive of 12 months CKD stage worsening.

Renal Function: Implications on the Surgical Treatment of RCC

The good oncologic results after partial nephrectomy for stage 1 RCC show that radical nephrectomy is an overtreatment in most cases, and that many healthy nephrons are removed unnecessarily. However, partial nephrectomy is a difficult operation, with increased blood loss and a higher risk of complications. Therefore, the advantage of preserved function has to be weighed up against the increased trauma of surgery in each individual patient, and the assessment of preoperative function may influence this decision, among other factors such as comorbidities and age. In most studies, renal function has been assessed by means of estimated glomerular filtration rate, and this parameter is very helpful for long-term studies in large populations. However, more precise measurement based on clearance studies are sometimes required for more sophisticated investigations. The technique of partial nephrectomy has evolved substantially in recent years, resulting in the preservation of more nephrons, less damage to the remaining parenchyma, less blood loss, and a decreased risk of complications. The introduction of minimally invasive surgery for this purpose has also decreased the overall morbidity of surgery. In the long-term, chronic kidney disease may result in increased cardiac mortality. There is ongoing discussion on this problem, however, this potential negative influence on overall survival is not only influenced by the rate of renal insufficiency, but also to a great extent by other comorbidities such as hypertension and diabetes. Therefore, in addition to providing the best surgery for any given patient, we have to make sure that the treatment of the comorbidities will also be part of our patient management, since the risk of cardiac failure may be greater than the risk of poor oncologic outcome.

Cause-Specific Mortality Among Survivors From T1N0M0 Renal Cell Carcinoma: A Registry-Based Cohort Study

Objective

More T1N0M0 renal cell carcinoma (RCC) is detected and the prognosis has improved, but, the current focus on non-RCC-related mortality is superficial. We investigated cause-specific mortality and its temporal patterns after an RCC diagnosis.

Methods

In the Surveillance, Epidemiology, and End Results-18 database, patients with T1N0M0 RCC treated with partial nephrectomy (PN) or radical nephrectomy (RN) during 2000-15 were identified. Standardized mortality ratios (SMRs) for cause of death were calculated. Risk predictors for each cause-specific mortality were investigated using the Fine and Gray sub-distribution model.

Results

In all, 68,612 eligible patients were pooled. A total of 14,047 (20.5%) patients had died (cardiovascular disease [CVD], 28.3%; other non-cancer-related diseases, 20.3%; RCC, 18.7%; other cancer types, 16.3%; non-disease events, 16.1%) during follow-up. Heart disease, diabetes mellitus, and cerebrovascular disease were the primary causes of non-RCC-related mortality within 1 year after the diagnosis. The greatest proportion of death (39.0%) occurred within 1-5 years after the diagnosis, mostly due to RCC itself, followed by heart disease. However, >5 years after the diagnosis, heart disease became the leading cause of death. Compared with the general US population, a 21% (SMR, 1.21; 95%CI 1.19-1.23) increased risk of all-mortality was observed; RCC patients had a higher risk of heart disease-related death within 5-10 years (SMR, 1.10; 95%CI 1.04-1.17) and >10 years (1.12; 1.02-1.22) after the diagnosis. Older age and RN increased the death risk of CVD and RCC-specific mortality. Although a larger tumor diameter increased the risk of RCC-specific death, this was not a significant predictor for CVD. Moreover, for T1N0M0 RCC tumors of diameter >4 cm, there was no significant difference in CVD incidence for RN vs. PN.

Conclusions

RCC-specific mortality is a common challenge for the prognosis. Importantly, a large proportion and higher SMRs of other non-RCC-related diseases (especially CVD) should not be disregarded for the better holistic management of survivors of local RCC. Targeted prevention strategies for non-RCC-related death could lead to significant reductions in mortality for RCC survivors.

Elective partial and radical nephrectomy in patients with renal cell carcinoma in CT1B stadium

Background/Aim. In renal cell carcinoma (RCC) the choice of surgical technique, radical (RN) or partial nephrectomy (PN) is still centre dependant because there still are no absolute recommendations for this approach. This study aims to analyze the oncological aspects, time until recurrent disease appears and cancer-specific survival in patients with RCC in T1bN0?0 depending on the type of surgical procedure partial or radical nephrectomy. Methods. A clinical observational study of a series of cases was conducted that analyzed data of 154 patients operated in our institution with a mean follow up a period not less than five years. The inclusion criteria included: renal tumours 4-7 cm, histopathological confirmation of RCC, absence of metastasis and normal serum creatinine. Exclusion criteria included: the presence of other malignancies, solitary functional kidney or comorbidities that can compromise renal function, bilateral tumours or unilateral multiple tumours. Results. The study analyzed data of 154 patients, 97 radical nephrectomies and 57 patients that underwent partial nephrectomy. Analyzing cancer-specific survival in four patients with RN there was a disease advancement that led to a lethal outcome, one PN patient died as a result of local relapse and distant metastasis. Conclusion. Based on our results PN is a good and safe treatment option for patients with RCC in T1b stadium. Partial nephrectomy offers a similar tumour control and better cancer-specific survival.

Outcomes of minimally invasive partial nephrectomy among very elderly patients: report from the RESURGE collaborative international database

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass. The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used. Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m2. PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01). In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available.

Transperitoneal vs retroperitoneal minimally invasive partial nephrectomy: comparison of perioperative outcomes and functional follow-up in a large multi-institutional cohort (The RECORD 2 Project)

BACKGROUND

Aim of this study was to evaluate and compare perioperative outcomes of transperitoneal (TP) and retroperitoneal (TR) approaches in a multi-institutional cohort of minimally invasive partial nephrectomy (MI-PN).

MATERIAL AND METHODS

All consecutive patients undergone MI-PN for clinical T1 renal tumors at 26 Italian centers (RECORd2 project) between 01/2013 and 12/2016 were evaluated, collecting the pre-, intra-, and postoperative data. The patients were then stratified according to the surgical approach, TP or RP. A 1:1 propensity score (PS) matching was performed to obtain homogeneous cohorts, considering the age, gender, baseline eGFR, surgical indication, clinical diameter, and PADUA score.

RESULTS

1669 patients treated with MI-PN were included in the study, 1256 and 413 undergoing TP and RP, respectively. After 1:1 PS matching according to the surgical access, 413 patients were selected from TP group to be compared with the 413 RP patients. Concerning intraoperative variables, no differences were found between the two groups in terms of surgical approach (lap/robot), extirpative technique (enucleation vs standard PN), hilar clamping, and ischemia time. Conversely, the TP group recorded a shorter median operative time in comparison with the RP group (115 vs 150 min), with a higher occurrence of intraoperative overall, 21 (5.0%) vs 9 (2.1%); p = 0.03, and surgical complications, 18 (4.3%) vs 7 (1.7%); p = 0.04. Concerning postoperative variables, the two groups resulted comparable in terms of complications, positive surgical margins and renal function, even if the RP group recorded a shorter median drainage duration and hospital length of stay (3 vs 2 for both variables), p < 0.0001.

CONCLUSIONS

The results of this study suggest that both TP and RP are feasible approaches when performing MI-PN, irrespectively from tumor location or surgical complexity. Notwithstanding longer operative times, RP seems to have a slighter intraoperative complication rate with earlier postoperative recovery when compared with TP.

Risk Factors for Upstaging, Recurrence, and Mortality in Clinical T1-2 Renal Cell Carcinoma Patients Upstaged to pT3a Disease: An International Analysis Utilizing the 8th Edition of the Tumor-Node-Metastasis Staging Criteria

OBJECTIVE

To investigate risk factors for and outcomes in pathological T3a-upstaging in Renal Cell Carcinoma (RCC), as Tumor-Node-Metastasis staging for T3a RCC was recently revised.

METHODS

Multicenter retrospective analysis of patients with clinical T1-T2 RCC, stratified by occurrence of pathologic T3a-upstaging. Primary outcome was recurrence-free survival (RFS). Multivariable analyses (MVA) were conducted for upstaging and recurrence. Kaplan-Meier analysis (KMA) was utilized for RFS and overall survival (OS).

RESULTS

We analyzed 2573 patients (1223 RN/1350 PN). Upstaging occurred in 360 (14.0%). On MVA, higher clinical stage was associated with increasing risk of upstaging [cT1a (referent), odds ratio for cT1b, cT2a, and cT2b was 2.6, 6.5, and 14.1, P < .001]. Higher clinical stage at presentation correlated with increasing risk of recurrence in pT3a-upstaged RCC (cT1a upstaged-pT3a [referent], hazard ratio [HR] for cT1b, cT2a, and cT2b upstaged pT3a was 1.16 [P = .729], 3.02 [P = .013], and 4.5 [P = .003]). Perirenal fat (HR 1.6, P = .038) and renal vein (HR 2.2, P = .006) invasion were associated with increased risk of recurrence; type of surgery was not (P = .157). KMA for RFS and OS in pT3a-upstaged patients demonstrated differences based on initial clinical stage (5-year PFS for cT1a/b, and cT2 upstaged was 84.5%/72.8%, and 44.7%, P < .001; 5-year OS for cT1 and cT2 upstaged was 83.8% and 63.2%, P < .001).

CONCLUSION

Risk of pT3a-upstaging and recurrence in pT3a-upstaged RCC correlates with clinical stage at presentation. Renal vein and perinephric fat invasion were associated with increased risk of recurrence. PN did not increase risk of recurrence and potential of pT3a-upstaging should not deter consideration of PN.

National Norwegian Practice Patterns for Surgical Treatment of Kidney Cancer Tumors ≤7cm: Adherence to Changes in Guidelines May Improve Overall Survival

BACKGROUND

Guidelines on surgical treatment for kidney cancer (KC) have changed over the last 10 yr. We present population-based data for patients with KC tumors ≤7cm from 2008 to 2013 to investigate whether surgical practice in Norway has changed according to guidelines.

OBJECTIVE

To assess the predictors of treatment and survival after KC surgery.

DESIGN, SETTING, AND PARTICIPANTS

We identified all surgically treated KC patients with tumors ≤7cm without metastasis diagnosed during 2008-2013 (2420 patients) from the Cancer Registry of Norway.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relationships with outcomes were analyzed using joinpoint regression, multivariate logistic regression, Kaplan-Meier survival estimates, Cox regression, relative survival (RS), and competing-risk analyses.

RESULTS AND LIMITATIONS

The mean follow-up was 5.2 yr. There was a 28% increase in the number of patients undergoing surgical treatment over the study period. Joinpoint regression revealed a significant annual increase in partial nephrectomy (PN) and a small reduction in radical nephrectomy (RN). PN increased from 43% to 66% for tumors ≤4cm and from 10% to 18% for tumors of 4.1-7cm. Minimally invasive (MI) RN increased from 53% to 72% and MI PN from 25% to 64%, of which 55% of procedures were performed with robotic assistance in 2013. The geographical distribution of treatment approaches differed significantly. Both PN and MI approaches were more frequent in high-volume hospitals. Cox regression analysis revealed that PN, age, and Fuhrman grade and stage were independent predictors of survival. There were no significant differences in cancer-specific survival (p=0.8). The 5-yr RS for T1a disease was higher after PN than after RN.

CONCLUSIONS

The rate of PN for tumors ≤7cm increased in the 6-yr study period. MI approaches increased for both RN and PN. This treatment shift coincides with the new guideline recommendations in 2010. The possible better survival for patients undergoing PN compared to RN indicates the importance of following evidence-based guidelines.

PATIENT SUMMARY

The use of partial nephrectomy and minimally invasive surgery for kidney cancer tumors increased in Norway from 2008 to 2013 according to population-based data, coinciding with guideline changes. The study illustrate that adherence to guidelines may improve patient outcomes.

Postoperative complications increase the risk of long-term chronic kidney disease after nephron-sparing surgery in patients with renal cancer and normal preoperative renal function

OBJECTIVES

To investigate whether postoperative complications affect long-term functional outcomes of renal patients treated with nephron-sparing surgery (NSS).

MATERIALS AND METHODS

We performed an observational study, enrolling 596 patients with preoperative normal renal function treated with NSS for clinical T1abN0M0 renal masses. Cox regression models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for chronic kidney disease (CKD) including as covariates age, comorbidity (scored according to the Charlson comorbidity index), hypertension, tumour size, preoperative estimated glomerular filtration rate (eGFR), eGFR < 60 mL/min/1.73 m² at discharge, and ischaemia time.

RESULTS

A total of 137 patients (23%) developed postoperative complications. At a median (interquartile range) follow-up of 53 (26-91) months, CKD risk was 19% for patients with postoperative complications and 11% for those without complications. Patients experiencing postoperative complications (HR 1.90, 95% CI 1.26-2.86) were at increased risk of developing CKD during the follow-up at multivariable analysis, after accounting for confounders.

CONCLUSIONS

Our data outline how postoperative complications might have a detrimental impact on postoperative renal function in patients submitted to NSS. Improper patient selection, increasing the risk of postoperative complications, could limit the benefit in terms of renal function brought by NSS.

Partial Versus Radical Nephrectomy for the Clinical T1a Renal Mass

For most patients with an anatomically straightforward cT1a renal mass, the decreased risk of CKD would likely outweigh the risk of transient perioperative morbidity. However, for patients who are old, comorbid, or frail, or for those with anatomically complex or high-risk tumors, these relative risks must be individualized to deliver personalized care.

The Impact of Surgical Strategy in Robot-assisted Partial Nephrectomy: Is It Beneficial to Treat Anterior Tumours with Transperitoneal Access and Posterior Tumours with Retroperitoneal Access?

Available comparison of transperitoneal robot-assisted partial nephrectomy (tRAPN) and retroperitoneal robot-assisted partial nephrectomy (rRAPN) does not consider tumour's location. The aim of this study was to compare perioperative morbidity, and functional and pathological outcomes after tRAPN and rRAPN, with the specific hypothesis that tRAPN for anterior tumours and rRAPN for posterior tumours might be a beneficial strategy. A large global collaborative dataset of 1169 cT1-2N0M0 patients was used. Propensity score matching, and logistic and linear regression analyses tested the effect of tRAPN versus rRAPN on perioperative outcomes. No differences were observed between rRAPN and tRAPN with respect to complications, operative time, length of stay, ischaemia time, median 1-yr estimated glomerular filtration rate (eGFR), and positive surgical margins (all p>0.05). Median estimated blood loss and postoperative eGFR were 50 versus100ml (p<0.0001) and 82 versus 78ml/min/1.73 m² (p=0.04) after rRAPN and tRAPN, respectively. At interaction tests, no advantage was observed after tRAPN for anterior tumours and rRAPN for posterior tumours with respect to complications, warm ischaemia time, postoperative eGFR, and positive surgical margins (all p>0.05). The techniques of rRAPN and tRAPN offer equivalent perioperative morbidity, and functional and pathological outcomes, regardless of tumour's location. PATIENT SUMMARY: Robot-assisted partial nephrectomy can be performed with a transperitoneal or a retroperitoneal approach regardless of the specific position of the tumour, with equivalent outcomes for the patient.

Partial versus Radical Nephrectomy for T1-T2 Renal Cell Carcinoma in Patients with Chronic Kidney Disease Stage III: a Multiinstitutional Analysis of Kidney Function and Survival Rate

BACKGROUND

To examine survival rates and renal function after partial nephrectomy (PN) and radical nephrectomy (RN) in patients with chronic kidney disease (CKD).

METHODS

We studied 4,332 patients who underwent PN or RN for pathological T1a-T2N0M0 renal cell carcinoma from 1988 to 2014. Patients were divided into two subgroups of CKD stage I-II and stage III. Kidney function, and survival outcomes were compared between groups.

RESULTS

We included 1,756 patients with CKD I-II and 276 patients with CKD III in the final pair-matched analysis. Kidney function was significantly better preserved in the PN than in the RN group among all patients. However, the beneficial effect of PN on kidney function gradually disappeared over time in CKD III patients. The 5-year overall survival (OS) rates after PN and RN differed in patients with CKD I-II disease (99.4% vs. 96.5%, respectively, P = 0.015). The 5-year OS rates after surgery were not affected by mode of nephrectomy in CKD III patients (97.8% vs. 93.5%, P = 0.103). The 5-year cancer-specific survival rates did not differ between treatment groups in all CKD stage. Cox hazard analysis showed that the operative method was a significant factor for OS in CKD I-II patients (hazard ratio [HR], 0.320; confidence interval [CI], 0.122-0.840; P = 0.021). However, PN was not beneficial in terms of OS in CKD III patients (HR, 0.395; CI, 0.086-1.172; P = 0.117).

CONCLUSION

PN is associated with a higher OS rate and better kidney function in patients with preoperative CKD stage I and II, but not in those with CKD stage III.

A Nomogram to Predict Significant Estimated Glomerular Filtration Rate Reduction After Robotic Partial Nephrectomy

BACKGROUND

Decreased functional outcome after partial nephrectomy is associated with overall mortality.

OBJECTIVE

To create a model that predicts ≥25% reduction from baseline estimated glomerular filtration rate (eGFR) in patients undergoing robot-assisted partial nephrectomy (RAPN) and to investigate the role of acute kidney injury (AKI) in this patient population.

DESIGN, SETTING, AND PARTICIPANTS

A total of 999 patients were identified from a multi-institutional database. Renal function was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for chronic kidney disease (CKD). AKI was defined as >25% reduction in eGFR from pre-RAPN period to discharge.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A nomogram to predict significant eGFR reduction (≥25% from baseline) in the time-frame between 3 and 15mo after RAPN was built based on the coefficients of Cox survival function that ultimately included age, sex, Charlson comorbidity index, baseline eGFR, RENAL nephrometry score, AKI in patients with normal baseline renal function, and AKI on CKD. Such landmark analysis was chosen in order to account for eGFR fluctuations occurring within the first 3mo of RAPN. The proportional hazard assumption was evaluated through the Schönfeld test. Internal validation was performed using the leave-one-out cross validation. Calibration was graphically investigated. The decision curve analysis (DCA) was used to evaluate the net clinical benefit.

RESULTS AND LIMITATIONS

Median (interquartile range [IQR]) age at surgery was 61yr (51, 68). Overall, 146 patients experienced significant eGFR reduction; median follow-up for survivors was 12.4mo. The 15-mo probability of significant eGFR reduction was 19%. All variables fitted into the model, including AKI in patients with normal renal function (hazard ratio [HR]: 4.51; 95% confidence interval [CI]: 3.12, 6.60; p<0.001) and AKI on CKD (HR: 4.90; 95% CI: 2.17, 11.1; p<0.001), emerged as predictors of significant eGFR reduction (all p≤0.048) and were considered to build a nomogram. The internally validated c index was 73%. The model demonstrated excellent calibration and a net benefit at the DCA with probabilities ≥4%.

CONCLUSIONS

We developed a nomogram that accurately predicts significant eGFR reduction after RAPN. This model may serve as a tool for early identification of patients at high risk for significant renal function decline after surgery.

PATIENT SUMMARY

We have developed a model for the prediction of renal function loss after partial nephrectomy for renal cancer.

Below Safety Limits, Every Unit of Glomerular Filtration Rate Counts: Assessing the Relationship Between Renal Function and Cancer-specific Mortality in Renal Cell Carcinoma

BACKGROUND

The hypothesis that renal function could influence oncological outcomes is supported by anecdotal literature.

OBJECTIVE

To determine whether estimated glomerular filtration rate (eGFR) is related to cancer-specific mortality (CSM) in patients who had undergone surgery for renal cell carcinoma (RCC).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of 3457 patients who underwent radical (39%) or partial nephrectomy (61%) for cT1-2 RCC between 1990 and 2015.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The eGFR was calculated by the Chronic Kidney Disease Epidemiology Collaboration equation. CSM was analyzed in a multivariable competing-risk framework, estimating the subdistribution hazard ratio (SHR) accounting for deaths from other causes. The relationship between eGFR and CSM was investigated from multiple statistical approaches-extended Cox regression with eGFR incorporated as a time-dependent covariate, landmark analysis, and joint modeling. Other predictors were selected by competing-risk random forest method and backward elimination.

RESULTS AND LIMITATIONS

The relationship between eGFR and CSM was graphically described by a linear spline, i.e. a continuous piecewise linear function with two lines joined by a knot. For eGFR treated as a time-dependent covariate, the knot was located at 65ml/min; at landmark analysis with eGFR at the baseline, 12 mo, and last functional follow-up, the knots were 85, 60, and 65ml/min, respectively. In multivariable competing-risk analysis, CSM was associated with eGFR only for values of eGFR below these cutoffs, with SHRs for every 10ml/min of reduction in eGFR of 1.25 (p=0.003), 1.16 (p=0.028), 1.44 (p=0.02), and 1.16 (p=0.042), corresponding to time-dependent eGFR, and eGFR at baseline, 12 mo, and last functional follow-up, respectively. Joint modeling confirmed these results. A retrospective design with inherent biases in data collection represents a limitation.

CONCLUSIONS

In patients undergoing surgery for RCC, renal function should be preserved in order to improve cancer-related survival.

PATIENT SUMMARY

The relationship between renal function and probability of dying due to renal cancer is complex. The present study found a correlation between glomerular filtration rate and cancer specific mortality that could reconsider the oncological role of renal function in patients undergoing surgery for renal cancer.

Role of Clinical and Surgical Factors for the Prediction of Immediate, Early and Late Functional Results, and its Relationship with Cardiovascular Outcome after Partial Nephrectomy: Results from the Prospective Multicenter RECORd 1 Project

PURPOSE

We sought to determine the predictors of short-term and long-term renal function impairment after partial nephrectomy.

MATERIALS AND METHODS

Clinical data on 769 consecutive patients who underwent partial nephrectomy were prospectively recorded at a total of 19 urological Italian centers from 2009 to 2012 in the RECORd 1 (Italian Registry of Conservative Renal Surgery) Project. We extracted clinical data on 708 of these patients who were alive, free of recurrent disease and with a minimum 2-year functional followup.

RESULTS

Of the patients 47.3% underwent open, 36.6% underwent laparoscopic and 16.1% underwent robot-assisted partial nephrectomy. The median baseline estimated glomerular filtration rate was 84.5 ml/minute/1.73 m² (IQR 69.9-99.1). Immediate (day 3 postoperatively), early (month 1) and late (month 24) renal function impairment greater than 25% from baseline was identified in 25.3%, 21.6% and 14.8% of cases, respectively. Female gender and the baseline estimated glomerular filtration rate were independent predictors of immediate, early and late renal function impairment. Age at diagnosis was an independent predictor of immediate and late impairment. Uncontrolled diabetes was an independent predictor of late impairment only. Open and laparoscopic approaches, and pedicle clamping were independent predictors of immediate and early renal function impairment. Overall 58 of 529 patients (11%) experienced postoperative cardiovascular events. Body mass index and late renal function impairment were independent predictors of those events.

CONCLUSIONS

Surgically modifiable factors were significantly associated with worse immediate and early functional outcomes after partial nephrectomy while clinically unmodifiable factors affected renal function during the entire followup. Late renal function impairment is an independent predictor of postoperative cardiovascular events.

R.E.N.A.L. Nephrometry Score: A Preoperative Risk Factor Predicting the Fuhrman Grade of Clear-Cell Renal Carcinoma

Objective: The purpose of this study was to evaluate the efficacy and feasibility of the R.E.N.A.L. Nephrometry Score to postoperatively predict high-grade clear-cell renal carcinoma (ccRCC). Methods: The study included 288 patients diagnosed with ccRCC who had complete CT/CTA data and R.E.N.A.L. Nephrometry Scores and underwent renal surgery at our center between January 2012 and December 2015. The relationship between the pathological grade of renal masses and R.E.N.A.L. Nephrometry Score was evaluated. Results: Univariate analysis indicated that diagnostic modality, cystic necrosis, enlargement of the regional lymph node, distant metastasis, clinical T stage, TNM stage, surgical modality, tumor size, nearness of the tumor to the collecting system or sinus, total Nephrometry Score and individual anatomic descriptor components were significantly associated with postoperative tumor grade (P < 0.05). Multivariate analysis showed that tumor size, the maximal diameter (R score), exophytic/endophytic properties (E score) and the location relative to the polar lines (L score) were independent prognostic factors to preoperatively predicting ccRCC pathological grade. The areas under the ROC curve with respect to the multi-parameter regression model (0.935, 95%CI: 0.904-0.966), tumor size (0.901, 95%CI: 0.866-0.937), R score (0.868, 95%CI: 0.825-0.911), E score (0.511, 95%CI: 0.442-0.581) and L score (0.842, 95%CI: 0.791-0.892) were calculated and compared. Conclusion: Tumor size, as well as R, E, and L scores were independent prognostic factors for high-grade pathology. Lager tumor sizes and higher R, E and L scores were more likely to be associated with high-grade pathological outcomes. Thus, the R.E.N.A.L. Score is of practical significance in facilitating urologists to make therapeutic decisions.

Analysis of survival for patients with chronic kidney disease primarily related to renal cancer surgery

OBJECTIVES

To evaluate predictors of long-term survival for patients with chronic kidney disease primarily due to surgery (CKD-S). Patients with CKD-S have generally good survival that approximates patients who do not have CKD even after renal cancer surgery (RCS), yet there may be heterogeneity within this cohort.

PATIENTS AND METHODS

From 1997 to 2008, 4 246 patients underwent RCS at our centre. The median (interquartile range [IQR]) follow-up was 9.4 (7.3-11.0) years. New baseline glomerular filtration rate (GFR) was defined as highest GFR between nadir and 6 weeks after RCS. We retrospectively evaluated three cohorts: no-CKD (new baseline GFR of ≥60 mL/min/1.73 m² ); CKD-S (new baseline GFR of <60 mL/min/1.73 m² but preoperative GFR of ≥60 mL/min/1.73 m² ); and CKD due to medical aetiologies who then require RCS (CKD-M/S, preoperative and new baseline GFR both <60 mL/min/1.73 m² ). Analysis focused primarily on non-renal cancer-related survival (NRCRS) for the CKD-S cohort. Kaplan-Meier analysis assessed the longitudinal impact of new baseline GFR (45-60 mL/min/1.73 m² vs <45 mL/min/1.73 m² ) and Cox regression evaluated relative impact of preoperative GFR, new baseline GFR, and relevant demographics/comorbidities.

RESULTS

Of the 4 246 patients who underwent RCS, 931 had CKD-S and 1 113 had CKD-M/S, whilst 2 202 had no-CKD even after RCS. Partial/radical nephrectomy (PN/RN) was performed in 54%/46% of the patients, respectively. For CKD-S, 641 patients had a new baseline GFR of 45-60 mL/min/1.73 m² and 290 had a new baseline GFR of <45 mL/min/1.73 m² . Kaplan-Meier analysis showed significantly reduced NRCRS for patients with CKD-S with a GFR of <45 mL/min/1.73 m² compared to those with no-CKD or CKD-S with a GFR of 45-60 mL/min/1.73 m² (both P ≤ 0.004), and competing risk analysis confirmed this (P < 0.001). Age, gender, heart disease, and new baseline GFR were all associated independently with NRCRS for patients with CKD-S (all P ≤ 0.02).

CONCLUSION

Our data suggest that CKD-S is heterogeneous, and patients with a reduced new baseline GFR have compromised survival, particularly if <45 mL/min/1.73 m² . Our findings may have implications regarding choice of PN/RN in patients at risk of developing CKD-S.

Nephron Sparing for Renal Cell Carcinoma: Whenever Possible?

Open studies have definitely and repeatedly favoured nephron-sparing surgery in improving overall, cancer-specific, and cardiac disease-specific survival in cases with a normal contralateral kidney. However, the only randomised clinical trial could not confirm this superiority of nephron-sparing surgery over radical nephrectomy.