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Yip W, Ghoreifi A, Gerald T, Lee R, Howard J, Asghar A, Khanna A, Cai J, Aron M, Gill I, Thompson RH, Uzzo R, Margulis V, Singla N, Djaladat H. Perioperative Complications and Oncologic Outcomes of Nephrectomy Following Immune Checkpoint Inhibitor Therapy: A Multicenter Collaborative Study. Eur Urol Oncol 2023; 6:604-610. [PMID: 37005212 DOI: 10.1016/j.euo.2023.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/14/2023] [Accepted: 03/11/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are now a mainstay of metastatic renal cell carcinoma (RCC) management with five current Food and Drug Administration-approved regimens. However, data regarding nephrectomy outcomes following an ICI are limited. OBJECTIVE To evaluate the safety and outcomes of nephrectomy following an ICI. DESIGN, SETTING, AND PARTICIPANTS A retrospective review was performed of patients with primary locally advanced or metastatic RCC undergoing nephrectomy following an ICI in five US academic centers between January 2011 and September 2021. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Clinical data, perioperative outcomes, and 90-d complications/readmissions were recorded and evaluated by univariate and logistic regression models. Recurrence-free and overall survival probabilities were estimated by the Kaplan-Meier method. RESULTS AND LIMITATIONS A total of 113 patients with a median (interquartile range) age of 63 (56-69) yr were included. The main ICI regimens were nivolumab ± ipilimumab (n = 85) and pembrolizumab ± axitinib (n = 24). Risk groups included 95% intermediate- and 5% poor-risk patients. Surgical procedures were 109 radical and four partial nephrectomies, including 60 open, 38 robotic, and 14 laparoscopic with five (10%) conversions. Two intraoperative complications were reported (bowel and pancreatic injury). The median operative time, estimated blood loss, and hospital stay were 3 h, 250 ml, and 3 d, respectively. A complete pathologic response (ypT0N0) was noted in six (5%) patients. The 90-d complication rate was 24%, with 12 (11%) patients requiring readmission. On a multivariable analysis, two or more risk factors (odds ratio [OR] 2.91, 95% confidence interval [CI]: 1.09, 7.42) and pathologic T stage ≥T3 (OR 4.21, 95% CI: 1.13-15.8) were independently associated with a higher 90-d complication rate. The 3-yr estimated overall survival and recurrence-free survival rates were 82% and 47%, respectively. Limitations include the retrospective nature and heterogeneous cohort in terms of clinicopathologic characteristics and ICI regimens received. CONCLUSIONS Nephrectomy following ICI therapy is feasible and a potential consolidative therapy option in select patients. Further research in the neoadjuvant setting is also warranted. PATIENT SUMMARY This study evaluates the outcomes of kidney surgery following immune checkpoint inhibitor therapy (mainly nivolumab and ipilimumab or pembrolizumab and axitinib) for patients with advanced kidney cancer. We utilized data from five academic centers across the USA and found that surgery in this setting did not have more complications or returns to the hospital than similar surgeries, indicating that it is a safe and feasible procedure at this time.
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Affiliation(s)
- Wesley Yip
- University of Southern California, Los Angeles, CA, USA
| | | | | | - Randall Lee
- Fox Chase Cancer Center - Temple Health, Philadelphia, PA, USA
| | | | - Aeen Asghar
- University of Southern California, Los Angeles, CA, USA; Fox Chase Cancer Center - Temple Health, Philadelphia, PA, USA
| | | | - Jie Cai
- University of Southern California, Los Angeles, CA, USA
| | - Manju Aron
- University of Southern California, Los Angeles, CA, USA
| | - Inderbir Gill
- University of Southern California, Los Angeles, CA, USA
| | | | - Robert Uzzo
- Fox Chase Cancer Center - Temple Health, Philadelphia, PA, USA
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Cai Q, Liu G, Liu Z, Gao M, Huang L, He F, Liu S, Lin Y, Wei H, Dou Z, Liu D, Hu Y, Gong X. Efficacy of quadratus lumborum block on postoperative pain and side effects in patients who underwent urological surgery: A meta-analysis. Pain Pract 2023; 23:70-82. [PMID: 35726437 DOI: 10.1111/papr.13140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/13/2022] [Accepted: 05/31/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Ultrasound-guided quadratus lumborum block (QLB) is considered a novel nerve block for postoperative pain control. However, its efficacy after urological surgery remains unclear. OBJECTIVES The purpose of the current meta-analysis was to evaluate the effects of the QLB block versus control (placebo or no injection) on postoperative pain and other adverse outcomes after urological surgery, providing extensive evidence of whether quadratus lumborum block is suitable for pain management after urological surgery. STUDY DESIGN Systematic review with meta-analysis of randomized clinical trials. METHODS We searched PubMed, Cochrane Library, Embase, Web of Science, and ClinicalTrials.gov to collect studies investigating the effects of QLB on analgesia after urological surgery. The primary outcomes included visual analog scale (VAS) at rest and during movement, 24-h postoperative morphine consumption, and the incidence of postoperative nausea and vomiting (PONV). RESULTS Overall, 13 randomized controlled trials (RCTs) were reviewed, including 751 patients who underwent urological surgery. The QLB group exhibited a lower VAS score postoperatively at rest or on movement at 0, 6, 12, and 24 h, with less 24-h postoperative morphine consumption and lower incidence of PONV. LIMITATIONS Although the result is stable, heterogeneity exists in the current research. CONCLUSIONS QLB exhibited a favorable effect of postoperative analgesia with reduced postoperative complications at rest or during movement after urological surgery. However, it is still a novel technology at a primary stage, which needs further research to develop.
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Affiliation(s)
- Qiang Cai
- Department of Orthopedics, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China.,Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | | | | | - Meiling Gao
- Department of Anesthesiology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Linsheng Huang
- Department of Hepatobiliary Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Fuhai He
- Guangxi Medical University, Nanning, China
| | | | - Yunhua Lin
- Guangxi Medical University, Nanning, China
| | - Huixia Wei
- Department of Anesthesiology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Zhiqian Dou
- Department of Obstetrics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Dexi Liu
- Department of Stomatology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yang Hu
- Department of Orthopedics, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Xingrui Gong
- Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
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García-Perdomo HA, Caparrós MJR, Asensio AA, Cabo AV. Effect of positive surgical margins in patients who undergo a partial nephrectomy regarding recurrence, overall survival, recurrence/progression-free survival, and metastasis-free survival. A systematic review and meta-analysis. Clin Genitourin Cancer 2022; 20:459-472. [DOI: 10.1016/j.clgc.2022.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 05/29/2022] [Indexed: 11/03/2022]
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Mina-Riascos SH, Vitagliano G, García-Perdomo HA. Effectiveness and safety of partial nephrectomy-no ischemia vs. warm ischemia: Systematic review and meta-analysis. Investig Clin Urol 2020; 61:464-474. [PMID: 32869563 PMCID: PMC7458877 DOI: 10.4111/icu.20190313] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 01/20/2023] Open
Abstract
PURPOSE This study aimed to determine the effectiveness and safety of partial nephrectomy (PN) without ischemia compared with PN with warm ischemia for reducing the deterioration in renal function in patients with cT1 renal tumors. MATERIALS AND METHODS We conducted a systematic review that included patients over 18 years of age who underwent PN with or without warm ischemia for cT1 renal tumors. The primary outcome was impaired renal function. A search strategy was performed in MEDLINE, EMBASE, LILACS, CENTRAL, the article reference lists, and the unpublished literature to reach saturation of the information. We assessed the risk of bias with the methodological index for nonrandomized studies (MINORS) tool, and we performed a meta-analysis according to the type of variable. RESULTS We found a total of 5,682 articles, of which 14 met the inclusion criteria. Seven studies evaluated renal function, identifying a difference in means (MD) of 3.50 (95% confidence interval [CI], 1.16 to 5.83), favoring no ischemia. We did not find any significant differences regarding intraoperative bleeding or operative time (MD, 55 mL; 95% CI, -33.16 to 144.08; and MD, 1.87; 95% CI, -20.47 to 24.21; respectively). CONCLUSIONS In this study, PN without ischemia showed a decrease in deterioration of the estimated glomerular filtration rate compared with warm ischemia.
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Affiliation(s)
| | - Gonzalo Vitagliano
- Oncology and Urolaparoscopy Unit, Urology Service, Hospital Alemán de Buenos Aires, Buenos Aires, Argentina
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Hemostatic agent use during partial nephrectomy: trends, outcomes, and associated costs. Int Urol Nephrol 2020; 52:2073-2078. [PMID: 32557376 DOI: 10.1007/s11255-020-02538-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate the ability of hemostatic agents (HA) to limit bleeding complications following partial nephrectomy (PN) and determine HA usage and costs as well as factors associated with post-operative bleeding complications. METHODS The records of 429 PN performed for kidney cancers were reviewed for clinical, pathologic, and perioperative variables. Surgical approach, HA use, and HA expenditure were determined. Bleeding complications and management to 90 days after PN were annotated. Wilcoxon rank-sum and two-sample t tests identified factors associated with HA use. Univariate and limited multivariate logistic regression determined variables associated with bleeding complications. RESULTS Use of HA was associated with longer OR duration, longer ischemia time, higher EBL, and method of PN (OPN and LPN > RPN) (all p values < 0.001). On bivariate analysis, while multiple factors were associated with bleeding complications, neither HA use (p = 0.924) nor the number of HA used (two agents vs one p = 0.712; three agents vs. one p = 0.606) were. A multivariable model noted that increasing RENAL score (p = 0.013) and surgical approach (OPN vs. RPN [p = 0.009] and LPN vs. RPN (p = 0.002]) were independently associated with bleeding complications, while HA use was not (p = 0.294). During the 16 years of analysis, a total of $77,687 USD was spent on HA. Average annual HA expenditure was $4855 USD with the peak being in 2010 where expense was $14,086. Mean annual costs for HA use were greater for OPN vs RAPN starting in 2013 (p = 0.02) CONCLUSIONS: The use of HA during PN was not associated with lower rates of bleeding complications. Therefore, judicious use in a case-specific manner is requisite to limit potentially unnecessary operative cost.
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Organ M, MacDonald LP, Jewett MAS, Ajzenberg H, Almatar A, Abdolell M, Acker MR, Rendon R. Classification tree for the prediction of malignant disease and the prediction of non-diagnostic biopsies in patients with small renal masses. Can Urol Assoc J 2018; 13:115-119. [PMID: 30059288 DOI: 10.5489/cuaj.5196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Preoperative prediction of benign vs. malignant small renal masses (SRMs) remains a challenge. This study: 1) validates our previously published classification tree (CT) with an external cohort; 2) creates a new CT with the combined cohort; and 3) evaluates the RENAL and PADUA scoring systems for prediction of malignancy. METHODS This study includes a total of 818 patients with renal masses; 395 underwent surgical resection and 423 underwent biopsy. A CT to predict benign disease was developed using patient and tumour characteristics from the 709 eligible participants. Our CT is based on four parameters: tumour volume, symptoms, gender, and symptomatology. CART modelling was also used to determine if RENAL and PADUA scoring could predict malignancy. RESULTS When externally validated with the surgical cohort, the predictive accuracy of the old CT dropped. However, by combining the cohorts and creating a new CT, the predictive accuracy increased from 74% to 87% (95% confidence interval 0.84-0.89). RENAL and PADUA score alone were not predictive of malignancy. One limitation was the lack of available histological data from the biopsy series. CONCLUSIONS The validated old CT and new combined-cohort CT have a predictive value greater than currently published nomograms and single-biopsy cohorts. Overall, RENAL and PADUA scores were not able to predict malignancy.
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Affiliation(s)
- Michael Organ
- Department of Urology, Memorial University, St. John's, NL, Canada
| | | | - Michael A S Jewett
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Henry Ajzenberg
- School of Medicine, Queen's University, Kingston, ON, Canada
| | - Ashraf Almatar
- Department of Urology, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Mohamed Abdolell
- Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada
| | - Matthew R Acker
- Department of Urology, Dalhousie University, Saint John, NB, Canada
| | - Ricardo Rendon
- Department of Urology, Dalhousie University, Halifax, NS, Canada
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