A population-based comparison of cancer-control rates between radical and partial nephrectomy for T1A renal cell carcinoma

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.

Trends in cause of death among patients with renal cell carcinoma in the United States: a SEER-based study

BACKGROUND

Renal cell carcinoma (RCC) survival has improved due to recent developments in RCC treatment. Therefore, other co-morbid conditions may have a more critical role. This study aims to explore the common causes of death in patients with RCC to improve the management and survival of RCC.

METHOD

We used the Surveillance, Epidemiology, and End Results (SEER) (1992-2018) database to get patients with RCC. We calculated the percentage of total deaths of six kinds of the cause of death (COD) and the cumulative incidence of death for each selected cause over survival time. The joinpoint regression was utilized to present the trend of mortality rate by COD.

RESULTS

We enrolled 107,683 cases with RCC. RCC was the leading cause of death in patients with RCC [25376(48.3%)], followed by cardiovascular diseases [9023(17.2%)], other cancers [8003 (15.2%)], other non-cancer diseases [4195 (8%)], non-disease cause [4023 (7.7%)], and respiratory diseases [1934 (3.6%)]. The proportion of patients who died of RCC decreased gradually over survival time, and this value decreased from 69.71% in 1992-1996 to 38.96% in 2012-2018. The non-RCC cause mortality rate showed an increasing trend, whereas a slight decrease was observed in RCC specific mortality rate. The distribution of such conditions varied across different patient populations.

CONCLUSION

RCC was still the primary COD of patients with RCC. However, non-RCC cause death was increasingly important among RCC patients in recent two decades. Cardiovascular disease and other cancers were crucial co-morbidities that required significant attention in the management of RCC patients.

Positive surgical margins may not affect the survival of patients with renal cell carcinoma after partial nephrectomy: A meta-analysis based on 39 studies

Background

So far, whether positive surgical margin(PSM) has adverse effects on the prognosis of patients is still controversial, so we designed this study to systematically evaluate the effect of PSM on the prognosis of patients with renal cell carcinoma (RCC) after partial nephrectomy (PN).

Methods

On the basis of three electronic databases (PubMed, Embase and the Cochrane Library) up to May 2022, all case-control studies (CCSs) comparing the effects of PSM and negative surgical margin (NSM) after PN on the oncological results of RCC patients were included. Two evaluators independently conducted a systematic literature search and extracted the data we needed. The methodological quality of all studies was evaluated by the modified Newcastle-Ottawa scale. The odds ratio (OR) was used to describe the results for dichotomous variables, and the meta-analysis was conducted using Cochrane Review Manager 5.2 and Stata 14.2.

Results

A total of 39 studies involving 21461 patients were included in our meta-analysis. The pooled results showed that the rates of tumor recurrence (OR 3.93, 95% CI 2.95-5.24; p < 0.00001) and metastasis (OR 4.63, 95% CI 3.11-6.88; p < 0.00001) in the PSM group were significantly higher than those in the NSM group. However, there were no significant differences in the rates of all-cause death (OR 1.35, 95% CI 0.92-1.99; p = 0.13) or cancer-specific death (OR 0.99, 95% CI 0.51-1.94; p = 0.99) between the two groups. In addition, subgroup analyses were carried out according to different average follow-ups, which revealed similar results.

Conclusion

Insignificant differences in survival between the PSM and NSM groups were observed, although significant differences in recurrence and metastasis in the PSM group were reported. Our study supported that close monitoring might be another effective choice for patients with PSM after PN. Considering the possible limitations, we recommended cautious interpretation of our results.

Therapeutic and Clinical Outcomes of Robot-assisted Partial Nephrectomy Versus Cryoablation for T1 Renal Cell Carcinoma

BACKGROUND

In cT1 renal cell carcinoma (RCC), very few studies have compared oncological outcomes and renal function preservation rates in nephron-sparing robot-assisted partial nephrectomy (RAPN) and percutaneous cryoablation (PCA).

PATIENTS AND METHODS

We retrospectively analysed 126 patients with cT1 RCC treated with RAPN (n=78) and computed tomography-guided PCA (n=48) between March 2016 and November 2019. Clinical data and outcomes were compared for the two groups.

RESULTS

There were no significant differences in the 3-year overall survival and relapse-free survival rates in the two groups (p=0.17 and p=0.093, respectively). The median percentage of estimated glomerular filtration rate preservation at 6 months after surgery was 91.8% and 91.4% in the RAPN and PCA groups, respectively (p=0.9).

CONCLUSION

In patients with cT1a RCC, oncological outcomes and renal function appear similar following RAPN and PCA.

Impact of radiological morphology of clinical T1 renal cell carcinoma on the prediction of upstaging to pathological T3

OBJECTIVES

Previous studies have reported that cases with clinical T1 renal cell cancer upstaging to pathological T3 are a risk factor to predicting postoperative recurrence after partial nephrectomy. The aim of our study was to investigate the impact of the radiological morphology of the enhanced CT scan of clinical T1 renal cell cancer on predicting upstaging to pathological T3.

METHODS

Three hundred sixty-seven cases with clinical T1 renal cell cancer diagnosed from enhanced CT scans were enrolled in this study. Based on the findings from the enhanced CT scan, the cases were classified into 'round', the margins of which were smooth and round; 'lobular', one or more findings of smooth dent and no spiky dent were identified on the margin of the tumor; and 'irregular', one or more spiky dent were identified on the margin of the tumor. The association of postoperative upstaging with these radiological morphology and other clinical characteristics of each case was analyzed.

RESULTS

Eighteen cases (4.9%) pathologically upstaged to T3a. Two round case (0.7%), 3 lobular cases (10.0%) and 13 irregular cases (22.0%) pathologically upstaged (P < 0.001, round + lobular versus irregular). Four of 17 cases (23.5%) with hilar tumors pathologically upstaged, while 14 of 350 cases (4%) with tumors pathologically upstaged in other sites (P < 0.001). Multivariate analysis revealed that irregular case was an independent factor in predicting upstaging to pathological T3a (P < 0.001).

CONCLUSIONS

Evaluation of the radiological morphology of clinical T1 renal cell cancer based on enhanced CT scans is useful for predicting pathological upstaging.

Oxymatrine Inhibits Renal Cell Carcinoma Progression by Suppressing β-Catenin Expression

Aims

Oxymatrine (OMT) has been identified to possess immunomodulatory, antiinflammatory and anticancer properties. This study aimed to investigate its precise function and the underlying molecular mechanisms in renal cell carcinoma progression.

Methods

The antineoplastic effect of oxymatrine was investigated by CCK-8 assay, cell cycle analysis, apoptosis assay, wound healing experiment, transwell assay, and drug-sensitivity analysis in renal cancer cells following oxymatrine treatment. The modulation of oxymatrine on β-catenin was analyzed through western blot and immunofluorescence assay. β-catenin overexpression was employed to determine the key role of β-catenin in oxymatrine-inhibited renal cell carcinoma in vitro. In addition, animal model was established to investigate the effect of oxymatrine on tumor growth in vivo.

Results

Oxymatrine inhibited renal cell carcinoma progression in vitro, including cell proliferation, apoptosis, migration, invasion and chemotherapy sensitivity. Further mechanistic studies demonstrated that oxymatrine exerted its antineoplastic effect through suppressing the expression of β-catenin. Moreover, in nude mice model, oxymatrine exhibited remarkable inhibition of tumor growth, which was consistent with our in vitro results.

Conclusions

Our findings illuminate oxymatrine as an effective antitumor agent in renal cell carcinoma, and suggest it a promising therapeutic application in renal cell carcinoma treatment.

Kidney Transplantation From Donors with Resectable Renal Cell Carcinoma: Two Case Reports

BACKGROUND

The existence of renal cell cancer (RCC) in a donated kidney may cause some confusion for clinicians. We aim to present our clinical experiences with 2 recipients who received an RCC-containing kidney from their living related donors.

METHODS

Two male patients received a kidney containing resectable size RCC from their living related donors. The recipients were discharged with well-functioning kidneys and currently are being monitored on standard follow-up protocols, and there is no evidence of RCC in their grafts.

RESULTS

The kidneys with resectable sizes of renal cell carcinoma were transplanted to the recipients after nephron-sparing surgery, with no sign of recurrent RCC in the 12-month follow-up period.

CONCLUSIONS

In the era of transplantation, the shortage of organ sources is the major barrier for the provision of organs to recipients. To enhance the graft donation pool, kidneys with resectable size RCC might be used in providing grafts to patients with end-stage kidney disease.

Survival benefit of nephron-sparing surgery for patients with pT1b renal cell carcinoma: A population-based study

The use of partial nephrectomy (PN) to treat patients with large renal cell carcinoma (RCC) remains controversial, particularly among elderly patients. The present study compared the improvement in cancer-specific survival (CSS) in patients with pT1b RCC who underwent either PN or radical nephrectomy (RN) and investigated the effects of age and sex on CSS. A total of 20,343 patients were identified in the Surveillance, Epidemiology and End Results database. Kaplan-Meier curves and Cox regression analysis were used to compare the CSS of patients who received PN vs. those who received RN. In total, 5,375 (26.42%) and 14,968 (73.58%) patients with pT1b RCC received PN and RN, respectively. Kaplan-Meier and Cox regression analysis indicated that PN resulted in an improved CSS compared with RN (P<0.001). In addition, PN was observed to be beneficial in male (P<0.001) and female patients <75 years of age. However, it was not beneficial for female patients of ≥75 years of age (P=0.197). These preliminary results warrant further investigation in clinical trials.

Surgical treatment for renal masses in the elderly: analysis of oncological, surgical and functional outcomes

PURPOSE

Radical treatment in elderly patients with renal tumor remains debatable due to uncertainties regarding the risk of surgical complications, risk of end-stage renal disease (ESRD) and survival benefit. The aim of the study was to assess outcomes of radical treatment for renal cancer in elderly patients.

MATERIALS AND METHODS

This retrospective analysis enrolled 507 consecutive patients treated with partial or radical nephrectomy due to renal mass. Patients with upfront metastatic disease (n=46) and patients lost to follow-up (n=110) were excluded from the analysis. Surgical, functional (screen for ESRD development) and survival outcomes were analyzed in patients aged >75 years in comparison to younger individuals.

RESULTS

The analyzed group included 55 elderly patients and 296 younger controls. Within the cohort a total of 148 and 203 patients underwent radical and partial nephrectomies respectively. The rate of surgical complications, including grade >3 Clavien- Dindo complications, did not differ between groups (3.6% vs. 4.4%, p=0.63). Median length of hospital stay was equal in both groups (7 days). During a follow-up (median 51.9 months, no difference between groups), ESRD occurred in 3.4% of controls and was not reported in elderly group (p=0.37). Younger patients demonstrated a statistically significant advantage in both overall survival and cancer-specific survival over elderly patients (OS 94.6% vs. 87% p=0.036, CSS 97.3% vs. 89.1% p=0.0008).

CONCLUSIONS

Surgical treatment in elderly patients with renal tumor is as safe as in younger individuals and does not increase the risk of ESRD. However, cancer specific survival among these patients remains shorter than in younger patients.

Hypertension and Cardiovascular Morbidity Following Surgery for Kidney Cancer

BACKGROUND

Despite better renal function following nephron-sparing surgery (NSS) relative to radical nephrectomy (RN), there is no consensus with respect to the long-term sequelae associated with surgery.

OBJECTIVE

To investigate the effect of surgery and the temporal pattern of two different cardiovascular event (CVe) categories after NSS versus RN.

DESIGN, SETTING, AND PARTICIPANTS

We collected data of 898 patients with cT1-2 N0 M0 renal mass and no history of CVe treated with NSS versus RN. CVe categories were dichotomised in (1) de novo hypertension (HT) and (2) other major cardiovascular events (MCEs).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariable competing regression analyses (MVAs) tested the adjusted effect of surgery type on each CVe category.

RESULTS AND LIMITATIONS

Among patients treated with RN, 38% of HT events occurred immediately after surgery. Conversely, in NSS counterparts, the onset of HT was diluted over the years after surgery (10% of HT events in the first 6 mo). When an MCE was considered, an increasing long-term time-dependent prevalence of the outcome was observed in both groups, with no statistically significantly difference between NSS and RN. At MVA, RN was associated with a higher HT risk (hazard ratio [HR] 2.89; p=0.006) than but a similar MCE risk (HR 0.85; p=0.6) to NSS.

CONCLUSIONS

Relative to RN, NSS showed an independent protective effect on HT but not on MCEs. In patients with no history of preoperative HT or MCEs, the onset of HT after RN is a very early event, due probably to the acute loss of renal parenchyma. This is not the case for the other cardiovascular morbidity, which develops in the long-term period, regardless of the type of surgery performed.

PATIENT SUMMARY

In renal cancer patients without a medical history of cardiopathy, preserving healthy kidney tissue at surgery is associated with a decreased risk of developing postoperative hypertension.

Radical versus partial nephrectomy, chronic kidney disease progression and mortality in US veterans

Background

Partial nephrectomy is considered the preferred care for localized kidney tumors and may yield better patient and kidney survival and similar oncological outcomes compared with radical nephrectomy. We sought to reexamine these hypotheses in a large nationally representative cohort of US veterans who underwent radical or partial nephrectomy.

Methods

We identified 7073 US veterans who had a partial or radical nephrectomy between 2004 and 2013. We collected data on estimated glomerular filtration rate (eGFR) prior to admission for nephrectomy surgery, immediately after surgery and 180 days postsurgery. We evaluated the association of nephrectomy type and eGFR at different time points with long-term mortality risk in adjusted survival models.

Results

Patients who underwent radical (compared to partial) nephrectomy had a 2-fold greater decline in eGFR (-21.8 ± 17.7 versus -10.3 ± 17.4 mL/min/1.73 m2) immediately after surgery. This larger drop in eGFR resulted in a larger proportion of radical nephrectomy patients having an eGFR <60 mL/min/1.73 m2 at ≥180 days postsurgery. Radical (compared to partial) nephrectomy patients also exhibited a 2.2-fold higher mortality [adjusted death hazard ratio 2.21 (95% confidence interval 1.91-2.55)]. Low eGFRs prior to surgery and 180 days postsurgery were associated with higher risk of postnephrectomy death.

Conclusions

Worse postnephrectomy kidney function and higher mortality were observed with radical nephrectomy, and a low presurgical eGFR and a greater decrease in eGFR postsurgery were associated with worse mortality irrespective of the type of nephrectomy. Additional studies are needed to examine predictors of postnephrectomy outcomes.

Comparison of survival for partial vs. radical nephrectomy in young patients with T1a renal cell carcinoma treated at commission on cancer-accredited facilities and influence of comorbidities on treatment choice

PURPOSE

There is a paucity of data comparing effects of partial nephrectomy (PN) vs. radical nephrectomy (RN) on overall survival in young patients. In this study, the National Cancer Database was used to evaluate the survival outcomes of those treated with PN and RN, and influence of comorbidities on surgical treatment (PN vs. RN) in young patients while accounting for Charlson-Deyo Comorbidity Score (CDCS).

MATERIALS AND METHODS

Patients between 20 and 44 years old (n = 9,849) surgically treated for pT1a renal cell carcinoma between 2004 and 2013 were identified from the National Cancer Database. Kaplan-Meier log-rank analysis and Cox proportional hazards model were performed to compare overall survival and calculate the hazard ratio between those undergoing RN and PN. Binary logistic regression was used to calculate odds ratios for receiving RN compared to PN. The effect measures in all models were adjusted for potential confounding factors.

RESULTS

After adjusting for comorbidities, PN offered an overall survival advantage over RN (P<0.001, hazard ratio = 0.464, 95% CI: 0.359-0.601) at a mean follow-up of 48.4 months (0-130.96), including young patients with no comorbidities (P<0.001). Compared to those with a CDCS = 0, patients were more likely to be treated with RN if they had a CDCS>1 (odds ratios = 2.049, 95% CI: 1.527-2.750).

CONCLUSIONS

Young patients treated with PN demonstrate an overall survival advantage. This survival advantage is observed after an early follow-up even in those without comorbidities. It is still not clear if the survival advantage seen is due to treatment itself or selection bias.

Positive surgical margins during partial nephrectomy for renal cell carcinoma: Results from Canadian Kidney Cancer information system (CKCis) collaborative

INTRODUCTION

We sought to determine the incidence, risk factors, and prognosis for patients with positive surgical margin (PSM) during partial nephrectomy (PN) for renal cell carcinoma (RCC).

METHODS

From the Canadian Kidney Cancer information system (CKCis) database, a historical cohort of PN patients with PSM were identified and compared to negative surgical margin (NSM). Risk factors for PSM were examined through multivariable logistic regression. Kaplan-Meier curves were used to compare progression-free survival.

RESULTS

Of 1103 patients, 972 (88.1%), 71 (6.4%), and 60 (5.4%) had NSM, PSM, and unknown status, respectively. Median patient age and tumour size were 61 years and 3.0 cm for both groups. From multivariable analysis, pathological stage ≥T3 (odds ratio [OR] 2.51; 95% confidence interval [CI] 1.13-5.60) and Fuhrman grade 4 (OR 5.35; 95% CI 1.11-25.72) were associated with PSM, whereas age, operative technique, and tumour size were not. Forty-nine (5.0%) patients from the NSM cohort and seven (9.9%) from the PSM cohort had a local/systemic progression of disease (adjusted hazard ratio [HR] 1.4; 95% CI 0.6-3.6). There were three (0.3%) cancer-related deaths in the NSM group and none in the PSM group. After median followup of 19 (interquartile range [IQR] 5-42) and 15 (IQR 7-30) months, 855 (91.4%) and 61 (89.7%) patients were alive in the NSM and PSM groups, respectively.

CONCLUSIONS

PSM occurred in 6.4% of PNs performed for RCC in this pan-Canadian cohort. Higher stage and grade are associated with a higher risk of positive margin. The small association between a PSM and progression suggests that complete nephrectomy is not necessary in patients with a PSM. The main study limitations are lack of nephrometry score and possible reporting bias.

Experiences of renal transplants from donors with renal cell carcinoma after ex vivo partial nephrectomy

Purpose

Routine evaluation of kidney donors occasionally reveals an incidental renal mass with an otherwise satisfactory kidney function. The use of such a kidney with an enhancing mass for transplantation is a matter of debate owing to a possible risk of transmission of donor malignancies. We report our experience of kidney transplants from donors with renal cell carcinoma, after ex vivo resection of the renal mass.

Methods

Two women aged 44 and 56 years were diagnosed with enhancing renal masses measuring 0.9 cm and 0.7 cm, respectively, during donor evaluation for kidney transplantation. Both patients and their families were informed of a potential risk of recurrent renal cell carcinoma following transplantation.

Results

Renal function test results of both donors satisfied the living donor selection criteria. Laparoscopic live donor nephrectomy was performed with ex vivo resection of renal masses on the bench table. Immediate pathological analysis revealed a renal cell carcinoma with a margin of normal renal parenchyma before transplantation. Regimens based on mammalian target of rapamycin inhibitors, which are known for their antitumoral properties, were used for immunosuppression in both recipients. None of the recipients showed recurrence or metastasis during the follow-up period, which was longer than 3 years after transplantation.

Conclusion

In light of the ongoing shortage of kidney donors, kidneys with small renal cell carcinoma could be considered for transplantation after appropriate removal of the lesion, with a very low risk of recurrent disease.

Disease progression and kidney function after partial vs. radical nephrectomy for T1 renal cancer

PURPOSE

Partial nephrectomy (PN) for early stage renal cancer preserves renal function better than radical nephrectomy (RN) and is generally considered oncologically similar. The Intergroup European Organisation for Research and Treatment of Cancer trial comparing outcomes after PN vs. RN, however, showed reduced overall survival in the PN group. Our aim was to evaluate recurrence, death, and renal function after PN vs. RN for T1 tumors in a Canadian population.

MATERIALS AND METHODS

From 2000 to 2015, 2,358 patients with a first occurrence of a clinical T1 renal cancer who underwent PN or RN were identified from the Canadian Kidney Cancer Information System. Clinical, surgical, and pathologic parameters were analyzed. Time to progression was compared after PN vs. RN using a Cox proportional hazards model, adjusted for pertinent variables.

RESULTS

Inclusion criteria were met in 1,615 PN and 743 RN. Preoperative characteristics appeared similar in both groups. Time to progression was not different after PN vs. RN, adjusted for potential confounders (hazard ratio = 1.17 [95% CI: 0.8-1.72, P = 0.42]). Postoperative estimated glomerular filtration rate at 1 and 3 years was significantly greater for PN vs. RN in a linear regression model, accounting for preoperative estimated glomerular filtration rate.

CONCLUSIONS

These results suggest that progression-free survival after PN and RN in patients with T1 renal cancer was similar, but that there was better preservation of renal function after PN. This suggests that both PN and RN have similar oncological efficiency, and that selection of surgical approach should be based on other factors such as technical feasibility, potential complications, and preservation of renal function.

Kidney function outcomes following thermal ablation of small renal masses

The diagnosis of small renal masses (SRMs) continues to increase likely attributable to widespread use of axial cross-sectional imaging. Many of these SRMs present in elderly patients with abnormal baseline renal function. Such patients are at risk for further decline following therapeutic intervention. Renal thermal ablation presents one approach for management of SRMs whereby tumors are treated in situ without need for global renal ischemia. These treatment characteristics contribute to favorable renal function outcomes following kidney tumor ablation particularly in patients with an anatomic or functional solitary renal unit.

Renal cancer

The diagnosis and management of renal cell carcinoma have changed remarkably rapidly. Although the incidence of renal cell carcinoma has been increasing, survival has improved substantially. As incidental diagnosis of small indolent cancers has become more frequent, active surveillance, robot-assisted nephron-sparing surgical techniques, and minimally invasive procedures, such as thermal ablation, have gained popularity. Despite progression in cancer control and survival, locally advanced disease and distant metastases are still diagnosed in a notable proportion of patients. An integrated management strategy that includes surgical debulking and systemic treatment with well established targeted biological drugs has improved the care of patients. Nevertheless, uncertainties, controversies, and research questions remain. Further advances are expected from translational and clinical studies.

Recovery of renal function after radical nephrectomy and risk factors for postoperative severe renal impairment: A Japanese multicenter longitudinal study

OBJECTIVES

To investigate longitudinal changes in renal function after radical nephrectomy, and to explore risk factors of postoperative severe renal impairment in a Japanese multicenter cohort.

METHODS

The present retrospective study included 701 patients who had no metastasis, end-stage kidney disease or bilateral kidney cancer, who underwent radical nephrectomy and who were followed up for at least 1 year. The longitudinal change in postoperative renal function during a 10-year follow-up period was evaluated according to the presence or absence of potential risk factors including greater age, chronic kidney disease, hypertension, diabetes mellitus and cardiovascular disease. A slope of annual change in estimated glomerular filtration rate was analyzed using a linear mixed model. Associations between the potential risk factors and a >50% estimated glomerular filtration rate decrease were evaluated using a multivariate Cox regression model.

RESULTS

Overall, the postoperative estimated glomerular filtration rate recovered over time with a significant positive slope of 0.34 mL/min/1.73 m(2)/year. Renal function did not tend to recover in patients with chronic kidney disease, hypertension, diabetes mellitus or cardiovascular disease. The multivariate analysis showed that greater age and diabetes mellitus were independent risk factors for severe renal impairment.

CONCLUSIONS

Overall, patients who had deteriorated renal function immediately after radical nephrectomy recovered over time. However, patients with chronic kidney disease, hypertension, diabetes mellitus and cardiovascular disease did not tend to recover renal function postoperatively. Greater age and diabetes mellitus were independent risk factors for a >50% decrease in estimated glomerular filtration rate.

Transplantation of kidneys with tumors

The shortage of donors in the face of the increasing number of patients wait-listed for renal transplantation has prompted several strategies including the use of kidneys with a tumor, whether found by chance on harvesting from a deceased donor or intentionally removed from a living donor and transplanted after excision of the lesion. Current evidence suggests that a solitary well-differentiated renal cell carcinoma, Fuhrman nuclear grade I-II, less than 1 cm in diameter and resected before grafting may be considered at minimal risk of recurrence in the recipient who, however, should be informed of the possible risk and consent to receive such a graft.

The management of small renal masses: what is likely to change?

The diffusion of imaging has determined an increased discovery of small renal masses (SRMs). Recent publications have been reviewed to present the state of the art in the management of SRMs and to try to foresee the next steps in this challenging condition. The role of percutaneous biopsies is expanding, since management algorithms include also active surveillance and ablative therapies. However up to 30% of biopsies fail to provide histological diagnosis and there is the risk of under-evaluating high-grade tumors. Active surveillance has been proposed in patients with reduced life expectancy and numerous comorbidities. The average growth of SRMs is slow, and metastatic progression has been observed in about 1%. Ablative therapies (cryotherapy and radiofrequency ablation) are used in patients with relevant comorbidities or advanced age and unfit for surgery, but who desire active treatment. Compared to conservative surgical treatment both techniques have increased local progression rates, while metastatic progression is relatively low.Partial nephrectomy (PN) is the recommended curative treatment for SRMs and can be performed open, laparoscopically or robotically. Open PN represents the benchmark, with similar cancer specific survival and better preservation of renal function compared to nephrectomy. Laparoscopy is comparable to open surgery in terms of oncologic results, but a long learning curve is necessary. Perioperative outcomes of robot-assisted PN appear superior to laparoscopy and the learning curve is shorter, but data for oncological results are still immature. With the increasing diffusion of robotic technology it is likely more SRMs will be managed with this approach.

Surgical management of stage T1 renal tumours at Canadian academic centres

INTRODUCTION

The proportion of patients with stage 1 renal tumours receiving partial nephrectomy is considered a quality of care indicator. The objective of this study was to characterize surgical practice patterns at Canadian academic institutions for the treatment of these tumours.

METHODS

The Canadian Kidney Cancer Information System (CKCis) is a multicentre collaboration of 13 academic institutions in Canada. All patients with pathologic stage T1 renal tumours in CKCis were identified. Descriptive statistics were performed to characterize practice patterns over time. Associations between patient, tumour, and treatment factors with the use of partial nephrectomy were determined.

RESULTS

From 1988 to April 2014, 1453 patients with pathologic stage 1 renal tumours were entered in the CKCis database. Of these, 977 (67%) patients had pT1a tumours; of these, 765 (78%) received partial nephrectomy. Of the total number of patients (1453), 476 (33%) had pT1b tumours; of these, 204 (43%) received partial nephrectomy. The use of partial nephrectomy increased over time from 60% to 90% for pT1a tumours and 20% to 60% for pT1b tumours. Stage pT1b (relative risk [RR] 0.56, 95% confidence interval [CI] 0.50-0.63) and minimally invasive surgical approach (RR 0.78, 95% CI 0.73-0.84 for pT1a and RR 0.23, 95% CI 0.17-0.30 for pT1b) were associated with decreased use of partial nephrectomy. Most patient factors including age, gender, body mass index, hypertension, and renal function were not significantly associated with use of partial nephrectomy (p > 0.05).

CONCLUSION

Almost all pT1a and most pT1b renal tumours managed surgically at academic centres in Canada receive partial nephrectomy. The use of partial versus radical nephrectomy appears to occur independently of patient age and comorbid status, which may indicate that urologists are performing partial nephrectomy whenever technically feasible based on tumour factors. Although the ideal proportion patients receiving partial nephrectomy cannot be determined, treatment distribution observed in this cohort may indicate an achievable case distribution among experienced surgeons.

Robotic nephron-sparing surgery for renal tumors: Current status

There have been a number of advances in robotic partial nephrectomy (RPN) for renal masses. We reviewed these advances with emphasis on the evolution of technique and outcomes as well as the expanding indications for RPN. Literature in the English language was reviewed using the National Library of Medicine database. Relevant articles were extracted, and their citations were utilized to broaden our search. The identified articles were reviewed and summarized with a focus on novel developments. RPN is an evolving procedure and is an emerging viable alternative to laparoscopic partial nephrectomy and open partial nephrectomy with favorable outcomes. The contemporary techniques used for RPN demonstrate excellent perioperative outcomes. The short-term oncologic outcomes are comparable to those of laparoscopic and open surgical approaches. Further studies are needed to assess long-term oncologic control.

Surgeon-specific factors affecting treatment decisions among Canadian urologists in the management of pT1a renal tumours

INTRODUCTION

The ubiquitous use of diagnostic imaging has resulted in an increased incidental detection of small renal masses (SRM). Patient- and tumour-related factors affect treatment decisions greatly; however, with multiple treatment options available, surgeon-specific characteristics and biases may also influence treatment recommendations. We determine the impact of surgeon-specific factors on treatment decisions in the management of SRM in Canada.

METHODS

An online survey study was conducted among Canadian urologists currently registered with the Canadian Urological Association. The questionnaire collected demographic information and recommended treatments for 6 SRM index cases involving theoretical patients of various ages (51-80 years) and comorbidities.

RESULTS

A total of 110 urologists responded (17% response rate) to the survey. Of these, 18% were over 65 years old and 45% were from academic centres. With increasing patient age and comorbidity, active surveillance and thermal ablative therapies were more the recommended treatment. Laparoscopic/robotic surgery was more commonly recommended by academic urologists and those under 65. Recommending surgery (radical nephrectomy or partial nephrectomy) for both elderly (about 80 years old) index patients correlated with surgeon age (surgeons over 65, p < 0.001), surgeons with no oncologic fellowship training (p = 0.021), surgeons with a non-academic practice (p = 0.003), surgeons with a personal history of cancer (p = 0.038) and surgeons with a family history of cancer death in the last 10 years (p = 0.022).

CONCLUSIONS

There are various factors that influence the management options offered to patients with SRMs. Our results suggest that surgeon age, personal history of cancer, practice-type and other surgeon-specific variables may affect treatments offered among urologists across Canada.

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.

Treatment outcomes of partial nephrectomy for T1b tumours

PURPOSE OF REVIEW

Nephron-sparing surgery is the standard of care for the treatment of localized renal tumours and is increasingly performed for larger and more challenging lesions. Aim of this review is to analyse the outcomes of partial nephrectomy for the treatment of T1b renal tumours greater than 4 cm in size.

RECENT FINDINGS

No randomized trial has compared the outcomes of partial nephrectomy compared to radical nephrectomy for T1b renal tumours. However, several single, multi-institutional and population-based studies consistently showed similar cancer-specific survival rates for open partial nephrectomy (OPN) and radical nephrectomy for tumours greater than 4 cm in size. A decreased loss in renal function was observed with partial nephrectomy compared to radical nephrectomy for T1b tumours. Laparoscopic partial nephrectomy (LPN) for tumours greater than 4 cm in size was shown to obtain similar short-to-intermediate-term oncological outcomes of laparoscopic radical nephrectomy and OPN in experienced centres, but is associated with longer warm ischaemia time and higher complication rates. The initial series of robot-assisted partial nephrectomy show similar perioperative results and decreased warm ischaemia time compared to LPN, whereas the oncological outcomes are still immature.

SUMMARY

Partial nephrectomy for T1b renal tumours achieves comparable oncological outcomes and better preservation of renal function compared to radical nephrectomy and should be performed whenever technically possible. OPN remains at present the gold standard technique. LPN represents an alternative to OPN in centres with advanced laparoscopic expertise. Robot-assisted partial nephrectomy has the potential to overcome the drawbacks of pure laparoscopic surgery, but larger series and longer follow-up are needed to further define its role in the management of T1b tumours.

Pilot study comparing the two hemostatic agents in patients undergoing partial nephrectomy

Background

Recently studies have demonstrated improved outcomes in patients undergoing nephron-sparing surgery (NSS) for low stage renal tumors, thus NSS is widely accepted as the treatment option for these patients. With NSS, there is a risk of renal hemorrhage and thus haemostatic agents may be routinely applied to the cut surface of the kidney. Herein we compare two commercially available haemostatic agents applied intra-operatively to the cut surface of the kidney. Post-operative outcomes (oncologic and non-oncologic) are reported.

Methods

The medical records of 23 patients with suspicious renal mass documented on axial imaging and who underwent open NSS via a mini-subcostal incision were extensively reviewed. One of two haemostatic agents (Floseal^®, n = 11; Arista^®, n = 12) was intra-operatively applied to the cut surface of the kidney. Chi-square and T- student test was used to compare outcomes between the cohort of 11 patients who had Floseal^® and the 12 patients who had Arista^®.

Results

Median pre-operative size of renal mass was 4.3 cm (range 1.5-7.0 cm). Final pathology revealed 3 oncocytomas and 20 renal cell carcinoma (17 clear cell, 1 chromophobe and 2 papillary), pT1a = 14 and pT1b = 6. Mean intra-operative blood loss and hospital stay between the Floseal^®vs. Arista^® cohorts did not significantly differ (227 mL vs. 250 mL, p = 0.68 and 4.4 days vs. 4.5 days, p = 0.76, respectively). Intra-operative and post-operative complications were not different between the two cohorts. No recurrences have been documented with a mean follow-up of 18 months.

Conclusion

Along with meticulous surgical technique, the use of either haemostatic agent (Floseal^® or Arista^®) was not associated with high rate of intra-operative or post-operative haemorrhage. Thus either haemostatic agent may be successfully used during NSS.

RENAL nephrometry scoring system: the radiologist's perspective

OBJECTIVE

The nephrometry score, which is determined from cross-sectional imaging, stratifies renal masses into low, intermediate, and high complexity. The purpose of this article is to understand how the score is determined and review the five key features that contribute to the nephrometry score.

CONCLUSION

The scoring system has implications for surgical planning and has been widely adopted by urologists but is less familiar to radiologists.

Renal cell carcinoma stage migration in a single European centre over 25 years: effects on 5- and 10-year metastasis-free survival

PURPOSE

To assess renal cell carcinoma (RCC) stage migration in a large European academic centre series over 25 years and its possible impact on patients' metastasis-free survival.

METHODS

The pathology reports of 2,333 consecutive patients with RCC who underwent nephrectomy from 1984 to 2006 at our institution were systematically re-evaluated. Patients were pooled into four groups according to the date of surgery: group 1: 1984-1989, group 2: 1990-1995, group 3: 1996-2001 and group 4: 2002-2006, respectively. Changes in pT-categories over time and the impact on 5- and 10-year metastasis-free survival were evaluated.

RESULTS

Organ-confined (pT1 and pT2) tumours were found in 191/502 (38.0 %) and 372/535 (69.5 %) surgical specimens in groups 1 and 4, respectively (p < 0.001). This stage migration was mainly the result of an increase in pT1a tumours (overall: 32.6 %) from 12.5 % in group 1 to 45.8 % in group 4 and a decrease in pT3a tumours (overall: 24.1 %) from 46.6 % in group 1 to 11.0 % in group 4 (p < 0.001). The mean tumour size decreased from 6.7 cm in group 1 to 4.8 cm in group 4 (p < 0.001). In 2,152 patients with non-metastatic RCC, median follow-up was 76.2 (interquartile range: 36.2-133.9) months. Five- and 10-year metastasis-free survival probabilities were 78.7 and 71.9 % in group 1, 85.3 and 80.0 % in group 2, and 86.9 and 82.7 % in group 3, respectively. Five-year metastasis-free survival in group 4 was 90.3 % (p < 0.001).

CONCLUSION

A statistically significant stage migration towards organ-confined RCC was observed in the cohort studied. This stage migration was accompanied by a significant improvement in metastasis-free survival comparing the period 1984-1989 and following time periods.

A comparative cost analysis of robot-assisted versus traditional laparoscopic partial nephrectomy

BACKGROUND AND PURPOSE

Robot-assisted laparoscopic partial nephrectomy (RALPN) is supplanting traditional laparoscopic partial nephrectomy (LPN) as the technique of choice for minimally invasive nephron-sparing surgery. This evolution has resulted from potential clinical benefits, as well as proliferation of robotic systems and patient demand for robot-assisted surgery. We sought to quantify the costs associated with the use of robotics for minimally invasive partial nephrectomy.

METHODS

A cost analysis was performed for 20 consecutive robot-assisted partial nephrectomy (RPN) and LPN patients at our institution from 2009 to 2010. Data included actual perioperative and hospitalization costs as well as professional fees. Capital costs were estimated using purchase costs and amortization of two robotic systems from 2001 to 2009, as well as maintenance contract costs. The estimated cost/case was obtained using total robotic surgical volume during this period. Total estimated costs were compared between groups. A separate analysis was performed assuming "ideal" robotic utilization during a comparable period.

RESULTS

RALPN had a cost premium of +$1066/case compared with LPN, assuming actual robot utilization from 2001 to 2009. Assuming "ideal" utilization during a comparable period, this premium decreased to +$334; capital costs per case decreased from $1907 to $1175. Tumor size, operative time, and length of stay were comparable between groups.

CONCLUSIONS

RALPN is associated with a small to moderate cost premium depending on assumptions regarding robotic surgical volume. Saturated utilization of robotic systems decreases attributable capital costs and makes comparison with laparoscopy more favorable. Purported clinical benefits of RPN (eg, decreased warm ischemia time, increased utilization of nephron-sparing surgery) need further study, because these may have cost implications.

Survival after partial and radical nephrectomy for the treatment of stage T1bN0M0 renal cell carcinoma (RCC) in the USA: a propensity scoring approach

Study Type - Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Partial nephrectomy has become the standard of care for T1a renal tumours, and the application of nephron-sparing techniques has increasingly been expanded to patients with localized T1b cancers. However, the relative efficacy of partial versus radical nephrectomy for these medium-sized tumours has yet to be definitively established. This study employs a propensity scoring approach within a large US population-based cohort to determine that no survival differences exist among patients with T1b renal tumours undergoing partial versus radical nephrectomy.

OBJECTIVES

To compare survival after partial nephrectomy (PN) vs radical nephrectomy (RN) among patients with stage TIb renal cell carcinoma (RCC) using a propensity scoring approach. Propensity score analysis is a statistical methodology that controls for non-random assignment of patients in observational studies.

PATIENTS AND METHODS

Using the Surveillance, Epidemiology, and End Results registry, 11,256 cases of RCCs of 4-7 cm that underwent PN or RN between 1998 and 2007 were identified. Propensity score analysis was used to adjust for potential differences in baseline characteristics between patients in the two treatment groups. Overall survival (OS) and cancer-specific survival (CSS) of patients undergoing PN vs RN was compared in stratified and adjusted analysis, controlling for propensity scores.

RESULTS

In all, 1047 (9.3%) patients underwent PN. For the entire cohort, no difference in survival was found in patients treated with PN as compared with RN, as shown by the adjusted hazard ratio (HR) for OS (1.10; 95% confidence interval [CI]: 0.91-1.36) and renal-CSS (HR 0.91; 95% CI: 0.65-1.27).   When the cohort was stratified by tumour size and age, no difference in survival was identified between the groups.

CONCLUSIONS

Even when stratified by tumour size and age, a survival difference between PN and RN in a propensity-adjusted cohort of patients with T1b RCC could not be confirmed.  If validated in prospective studies, PN may become the preferred treatment for T1b renal tumours in centres experienced with nephron-sparing surgery.

Impact of repeated hilar clamping on renal function during laparoscopic and robot-assisted partial nephrectomy

BACKGROUND AND PURPOSE

Conventional wisdom and small animal studies suggest repeated hilar clamping during partial nephrectomy is deleterious to renal function. We describe the impact of repeated renal hilar clamping during laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RPN) on the overall function of the operated kidney.

PATIENTS AND METHODS

A retrospective analysis of all patients undergoing RPN or LPN with repeated hilar clamping was performed. Patient and tumor characteristics were recorded. All patients had preoperative and postoperative mercaptoacetyltriglycine (MAG)3 renal scans, and the change in function was calculated. Change in glomerular filtration rate (GFR) was calculated with the modified Modification of Diet in Renal Disease equation as well.

RESULTS

Seven patients were studied with an average age of 60 and a body mass index of 32. Tumors averaged 3.6 cm, and there were four and three right- and left-sided tumors, respectively. The reasons for repeated clamping were bleeding in three patients and either gross or microscopic positive margins in four patients, all of whom had repeated resection. The average initial clamp time was 20 minutes, and the average reclamp time was 12 minutes. The average operative time was 185 minutes. and average blood loss was 171 mL. All renal units were functioning postoperatively. The average change in absolute renal function on the operated kidney was -4.9%, and the relative loss of function was -10%, both measured on MAG3 scan. The average GFR before surgery was 61.4 (mL/min/1.73m(2)); after surgery, the average GFR was 57.1 (mL/min/1.73m(2)), for an average loss of -7%. The range of change in GFR was from 0% to -23%.

CONCLUSIONS

Although not optimal, repeated clamping of the renal hilum during partial nephrectomy to control bleeding or to obtain a clear surgical margin is associated with minimal loss of renal function.

Developments in kidney tumor nephrometry

With the widespread use of computed tomography imaging, the majority of renal tumors are currently detected incidentally at lower grade and stage. Partial nephrectomy has become the preferred treatment for many of these smaller, lower-stage, organ-confined tumors. Compared with radical nephrectomy, partial nephrectomy is more technically difficult to perform. Specific tumor features such as tumor size, depth, location, and proximity to the kidney vasculature and urinary collecting system affect the difficulty of resection. Classically, feasibility of resection has been determined subjectively. Recently, 3 methodologies have been proposed to provide standard, more objective preoperative assessment of tumor anatomy. These "nephrometry" systems include the R.E.N.A.L., PADUA, and C-index systems. In this article, we review aspects of each of these systems, their similarities and differences, and their relevance to clinical practice and academic reporting.

Treatment of localised renal cell carcinoma

CONTEXT

The increasing incidence of localised renal cell carcinoma (RCC) over the last 3 decades and controversy over mortality rates have prompted reassessment of current treatment.

OBJECTIVE

To critically review the recent data on the management of localised RCC to arrive at a general consensus.

EVIDENCE ACQUISITION

A Medline search was performed from January 1, 2004, to May 3, 2011, using renal cell carcinoma, nephrectomy (Medical Subject Heading [MeSH] major topic), surgical procedures, minimally invasive (MeSH major topic), nephron-sparing surgery, cryoablation, radiofrequency ablation, surveillance, and watchful waiting.

EVIDENCE SYNTHESIS

Initial active surveillance (AS) should be a first treatment option for small renal masses (SRMs) <4 cm in unfit patients or those with limited life expectancy. SRMs that show fast growth or reach 4 cm in diameter while on AS should be considered for treatment. Partial nephrectomy (PN) is the established treatment for T1a tumours (<4 cm) and an emerging standard treatment for T1b tumours (4-7 cm) provided that the operation is technically feasible and the tumour can be completely removed. Radical nephrectomy (RN) should be limited to those cases where the tumour is not amenable to nephron-sparing surgery (NSS). Laparoscopic radical nephrectomy (LRN) has benefits over open RN in terms of morbidity and should be the standard of care for T1 and T2 tumours, provided that it is performed in an advanced laparoscopic centre and NSS is not applicable. Open PN, not LRN, should be performed if minimally invasive expertise is not available. At this time, there is insufficient long-term data available to adequately compare ablative techniques with surgical options. Therefore ablative therapies should be reserved for carefully selected high surgical risk patients with SRMs <4 cm.

CONCLUSIONS

The choice of treatment for the patient with localised RCC needs to be individualised. Preservation of renal function without compromising the oncologic outcome should be the most important goal in the decision-making process.