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Ellis JL, Sontag-Milobsky I, Chen VS, Rac G, Hartman NC, Gorbonos A, Woods ME, Flanigan RC, Quek M, Patel HD, Gupta GN. Quantifying preserved renal volume and function in patients undergoing standard partial nephrectomy vs. tumor enucleation for localized renal tumors. Urol Oncol 2024:S1078-1439(24)00659-8. [PMID: 39370308 DOI: 10.1016/j.urolonc.2024.09.018] [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: 02/21/2024] [Revised: 09/02/2024] [Accepted: 09/14/2024] [Indexed: 10/08/2024]
Abstract
INTRODUCTION Renal parenchymal volume loss from standard partial nephrectomy (SPN) is a significant prognosticator for postoperative renal function. Tumor enucleation (TE) minimizes parenchymal loss compared to SPN. Little is known regarding discrete changes in renal function associated with volume loss. We sought to quantify the differences between SPN and TE in preserving parenchymal volume and estimated glomerular filtration rate (eGFR). METHODS We identified 420 patients who underwent robotic partial nephrectomy (SPN or TE) at our tertiary care center from 2009 to 2022. Parenchymal volumes were calculated using TeraRecon 3D reconstruction software from axial imaging performed preoperatively and within 6 months postoperatively. Renal volume preserved and renal function were evaluated with multivariable linear and logistic regression models. RESULTS At 1 year, eGFR was 7% lower in patients undergoing SPN compared to TE (P < 0.01). Across both SPN and TE, only volume of preserved parenchyma was predictive of eGFR and chronic kidney disease (CKD) progression (both P < 0.01). TE preserved more healthy parenchymal volume compared to SPN (median percentage 97.6% vs 89.2%; P < 0.001). Each 1% of volumetric loss corresponded to a 0.35% decrease in eGFR at 1 year postoperatively (P < 0.01). CONCLUSIONS Volume of preserved renal parenchyma was the strongest factor associated with preserved eGFR and reduced odds of CKD progression. TE preserved more parenchyma than SPN, which translated to higher eGFR preservation at 1 year postoperatively.
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Affiliation(s)
- Jeffrey L Ellis
- Department of Urology, Loyola University Medical Center, Maywood, IL.
| | | | - Victor S Chen
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Goran Rac
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Natalie C Hartman
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Alex Gorbonos
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Michael E Woods
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Robert C Flanigan
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Marcus Quek
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Hiten D Patel
- Department of Urology, Loyola University Medical Center, Maywood, IL; Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gopal N Gupta
- Department of Urology, Loyola University Medical Center, Maywood, IL; Department of Surgery, Loyola University Medical Center, Maywood, IL; Department of Radiology, Loyola University Medical Center, Maywood, IL
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Kazama A, Munoz-Lopez C, Attawettayanon W, Boumitri M, Maina E, Lone Z, Rathi N, Lewis K, Campbell RA, Palacios DA, Kaouk J, Haber GP, Haywood S, Almassi N, Weight CJ, Remer EM, Ward R, Nowacki AS, Campbell SC. Parenchymal obliteration by renal masses: Functional and oncologic implications. Urol Oncol 2024; 42:247.e11-247.e19. [PMID: 38729867 DOI: 10.1016/j.urolonc.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/14/2024] [Accepted: 04/18/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVES Most renal tumors merely displace nephrons while others can obliterate parenchyma in an invasive manner. Substantial parenchymal volume replacement (PVR) by renal cell carcinoma (RCC) may have oncologic implications; however, studies regarding PVR remain limited. Our objective was to evaluate the oncologic implications associated with PVR using improved methodology including more accurate and objective tools. PATIENTS/METHODS A total of 1,222 patients with non-metastatic renal tumors managed with partial nephrectomy (PN) or radical nephrectomy (RN) at Cleveland Clinic (2011-2014) with necessary studies were retrospectively evaluated. Parenchymal volume analysis via semiautomated software was used to estimate split renal function and preoperative parenchymal volumes. Using the contralateral kidney as a control, %PVR was defined: (parenchymal volumecontralateral-parenchymal volumeipsilateral) normalized by parenchymal volumecontralateral x100%. PVR was determined preoperatively and not altered by management. Patients were grouped by degree of PVR: minimal (<5%, N = 566), modest (5%-25%, N = 414), and prominent (≥25%, N = 142). Kaplan-Meier was used to evaluate survival outcomes relative to degree of PVR. Multivariable Cox-regression models evaluated predictors of recurrence-free survival (RFS). RESULTS Of 1,122 patients, 801 (71%) were selected for PN and 321 (29%) for RN. Overall, median tumor size was 3.1 cm and 6.8 cm for PN and RN, respectively, and median follow-up was 8.6 years. Median %PVR was 15% (IQR = 6%-29%) for patients selected for RN and negligible for those selected for PN. %PVR correlated inversely with preoperative ipsilateral GFR (r = -0.49, P < 0.01) and directly with advanced pathologic stage, high tumor grade, clear cell histology, and sarcomatoid features (all P < 0.01). PVR≥25% associated with shortened recurrence-free, cancer-specific, and overall survival (all P < 0.01). Male sex, ≥pT3a, tumor grade 4, positive surgical margins, and PVR≥25% independently associated with reduced RFS (all P < 0.02). CONCLUSIONS Obliteration of normal parenchyma by RCC substantially impacts preoperative renal function and patient selection. Our data suggests that increased PVR is primarily driven by aggressive tumor characteristics and independently associates with reduced RFS, although further studies will be needed to substantiate our findings.
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Affiliation(s)
- Akira Kazama
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Department of Urology, Molecular Oncology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Carlos Munoz-Lopez
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Worapat Attawettayanon
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Division of Urology, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkhla, Thailand
| | - Melissa Boumitri
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Eran Maina
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Zaeem Lone
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Nityam Rathi
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Kieran Lewis
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Rebecca A Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | - Jihad Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | - Samuel Haywood
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Nima Almassi
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | | | - Ryan Ward
- Imaging Institute, Cleveland Clinic, Cleveland OH
| | - Amy S Nowacki
- Department of Quantitative Sciences, Cleveland Clinic, Cleveland, OH
| | - Steven C Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
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Xiong L, Zou X, Luo X, Yin S, Huang Y, Ning K, Wen D, Zhou Z, Wang J, Li Z, Chen J, Li J, Peng W, Guo S, Dong P, Zhou F, Han H, Peng Y, Yu C, Zhang Z. Longitudinal changes in renal parenchymal volume and function status after partial nephrectomy: a retrospective cohort study. Int J Surg 2024; 110:984-991. [PMID: 38000077 PMCID: PMC10871623 DOI: 10.1097/js9.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND The ipsilateral renal parenchymal volume (RPV) experiences a sharp decrease shortly after partial nephrectomy (PN), mainly due to surgical remove or devascularization of kidney tissue. However, the subsequent change of RPV and its association with glomerular filtration rate (GFR) fast decline remains unknown. Our objective was to investigate the change of ipsilateral RPV and renal function status from new baseline (1-12 months after PN) to latest follow-up (≥1 year) after PN, and to explore factors associated with ipsilateral RPV decrease rate and correlation between RPV decrease and GFR fast decline. MATERIALS AND METHODS A retrospective review of 367 patients with PN was conducted. Three-dimensional reconstruction of computed tomography (CT)/MRI images was performed for RPV calculation. Spectrum score was used to assess the degree of acute kidney injury (AKI) in the operated kidney after PN. GFR decline greater than 3 ml/min/1.73 m 2 /year was defined as GFR fast decline. One hundred fourteen patients underwent abdominal surgery was used as control. Predictive factors for subsequent decrease of RPV rate and GFR fast decline were evaluated by linear and logistic regression, respectively. RESULTS With a median interval time of 21.1 (interquartile range:13.8-35.5) months, median ipsilateral RPV significantly decreased from 118.7 (interquartile range:100.7-137.1) ml at new baseline to 111.8 (IQR: 92.3-131.3) ml at latest follow-up. The interval time [β: 1.36(0.71-2.01), P <0.001] and spectrum score [β: 5.83 (2.92-8.74), P <0.001] were identified as independent predictors of ipsilateral RPV decrease rate. GFR fast decline was observed in 101 (27.5%) patients. Annual ipsilateral RPV decrease rate [odds ratio:1.67 (1.05-2.67), P =0.03] and overweight [odds ratio:1.63 (1.02-2.60), P =0.04] were independent predictors of GFR fast decline. CONCLUSIONS Ipsilateral RPV experienced a moderate but significant decrease during follow-up after PN, especially in those with severer acute kidney injury. The presence of GFR fast decline was found to be associated with reduction of ipsilateral RPV, particularly in overweight individuals.
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Zhang G, Wang B, Liu H, Jia G, Tao B, Zhang H, Wang C. How many cases are required to achieving early proficiency in purely off-clamp robot-assisted partial nephrectomy? Front Surg 2024; 10:1309522. [PMID: 38234451 PMCID: PMC10792019 DOI: 10.3389/fsurg.2023.1309522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 11/16/2023] [Indexed: 01/19/2024] Open
Abstract
Background and purpose Off-clamp robot-assisted partial nephrectomy (Offc-RAPN) is a technically challenging procedure that can effectively avoid renal ischemia owing to the absence of hilar vessel preparation and clamping. However, data on the learning curve (LC) for this technique are limited. The purpose of this study was to assess the LC of Offc-RAPN and compare the perioperative outcomes between different learning phases. Methods This retrospective study included 50 consecutive patients who underwent purely Offc-RAPN between January 2022 and April 2023. Multidimensional cumulative sum (CUSUM) analysis method was used to assess LC. Spearman's correlation and LOWESS analysis were performed to analyze the continuous variables of perioperative outcomes. Baseline characteristics and perioperative outcomes were compared using χ2-test, t-test and U-test. Results CUSUM analysis identified two LC phases: phase I (the first 24 cases) and phase II (the subsequent 26 cases). Phase II showed significant reductions in mean operative time (133.5 vs. 115.31 min; p = 0.04), mean console time (103.21 vs. 81.27 min; p = 0.01), and mean postoperative length of stay (5.33 vs. 4.30 days; p = 0.04) compared to phase I. However, no significant differences were observed in other perioperative outcomes or baseline characteristics between the two LC phases. Conclusions Offc-RAPN performed by a surgeon with experience in laparoscopic and robotic surgeries achieved early proficiency in 24 cases. Moreover, Offc-RAPN alone is safe and feasible even in the initial phase of the LC for an experienced surgeon.
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Affiliation(s)
| | | | | | | | | | | | - Chunyang Wang
- Department of Urology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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