Comparison of oncologic outcomes between partial nephrectomy and radical nephrectomy in patients who were upstaged from cT1 renal tumor to pT3a renal cell carcinoma: an updated systematic review and meta-analysis

[Predicting the 3-year tumor-specific survival in patients with T3a non-metastatic renal cell carcinoma]

OBJECTIVE

To predict the 3-year cancer-specific survival (CSS) of patients with non-metastatic T3a renal cell carcinoma after surgery.

METHODS

A total of 336 patients with pathologically confirmed T3a N0-1M0 renal cell carcinoma (RCC) who underwent surgical treatment at the Department of Urology, Peking University Third Hospital from March 2013 to February 2021 were retrospectively collected. The patients were randomly divided into a training cohort of 268 cases and an internal validation cohort of 68 cases at an 4 ∶ 1 ratio. Using two-way Lasso regression, variables were selected to construct a nomogram for predicting the 3-year cancer-specific survival (CSS) of the patients with T3aN0-1M0 RCC. Performance assessment of the nomogram included evaluation of discrimination and calibration ability, as well as clinical utility using measures such as the concordance index (C-index), time-dependent area under the receiver operating characteristic curve [time-dependent area under the curve (AUC)], calibration curve, and decision curve analysis (DCA). Risk stratification was determined based on the nomogram scores, and Kaplan-Meier survival analysis and Log-rank tests were employed to compare progression-free survival (PFS) and cancer-specific survival (CSS) among the patients in the different risk groups.

RESULTS

Based on the Lasso regression screening results, the nomogram was constructed with five variables: tumor maximum diameter, histological grading, sarcomatoid differentiation, T3a feature, and lymph node metastasis. The baseline data of the training and validation sets showed no statistical differences (P>0.05). The consistency indices of the column diagram were found to be 0.808 (0.708- 0.907) and 0.903 (0.838-0.969) for the training and internal validation sets, respectively. The AUC values for 3-year cancer-specific survival were 0.843 (0.725-0.961) and 0.923 (0.844-1.002) for the two sets. Calibration curves of both sets demonstrated a high level of consistency between the actual CSS and predicted probability. The decision curve analysis (DCA) curves indicated that the column diagram had a favorable net benefit in clinical practice. A total of 336 patients were included in the study, with 35 cancer-specific deaths and 69 postoperative recurrences. According to the line chart, the patients were divided into low-risk group (scoring 0-117) and high-risk group (scoring 119-284). Within the low-risk group, there were 16 tumor-specific deaths out of 282 cases and 36 postoperative recurrences out of 282 cases. In the high-risk group, there were 19 tumor-specific deaths out of 54 cases and 33 post-operative recurrences out of 54 cases. There were significant differences in progression-free survival (PFS) and cancer-specific survival (CSS) between the low-risk and high-risk groups (P < 0.000 1).

CONCLUSION

A nomogram model predicting the 3-year CSS of non-metastatic T3a renal cell carcinoma patients was successfully constructed and validated in this study. This nomogram can assist clinicians in accurately assessing the long-term prognosis of such patients.

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.

Partial Nephrectomy Versus Radical Nephrectomy for Endophytic Renal Tumors: Comparison of Operative, Functional, and Oncological Outcomes by Propensity Score Matching Analysis

Purpose

The study aimed to compare operative, functional, and oncological outcomes between partial nephrectomy (PN) and radical nephrectomy (RN) for entophytic renal tumors (ERTs) by propensity score matching (PSM) analysis.

Methods

A total of 228 patients with ERTs who underwent PN or RN between August 2014 and December 2021 were assessed. A PSM in a 1:1 ratio was conducted to balance the differences between groups. Perioperative characteristics, renal functional, and oncological outcomes were compared between groups. Univariate and multivariate logistic and Cox proportional hazard regression analyses were used to determine the predictors of functional and survival outcomes.

Results

After PSM, 136 cases were matched to the PN group (n = 68) and the RN group (n = 68). Patients who underwent RN had shorter OT, less EBL, and lower high-grade complications (all p <0.05) relative to those who underwent PN. However, better perseveration of renal function was observed in the PN group, which was reflected in 48-h postoperative AKI (44.1% vs. 70.6%, p = 0.002), 1-year postoperative 90% eGFR preservation (45.6% vs. 22.1%, p = 0.004), and new-onset CKD Stage ≥III at last follow-up (2.9% vs. 29.4%, p <0.001). RN was the independent factor of short-term (OR, 2.812; 95% CI, 1.369–5.778; p = 0.005) and long-term renal function decline (OR, 10.242; 95% CI, 2.175–48.240; p = 0.003). Furthermore, PN resulted in a better OS and similar PFS and CSS as compared to RN (p = 0.042, 0.15, and 0.21, respectively). RN (OR, 7.361; 95% CI, 1.143–47.423; p = 0.036) and pT3 stage (OR, 4.241; 95% CI, 1.079–16.664; p = 0.039) were independent predictors of overall mortality.

Conclusion

Among patients with ERTs, although the PN group showed a higher incidence of high-grade complications than RN, when technically feasible and with experienced surgeons, PN is recommended for better preservation of renal function, longer OS, and similar oncological outcomes.

Comparison of prognosis between patients undergoing radical nephrectomy versus partial nephrectomy for renal cell carcinoma ≤7 cm T3aN0/xM0: Survival benefit is biased toward partial nephrectomy

BACKGROUND

There is limited and controversial evidence on the prognosis of partial nephrectomy (PN) versus radical nephrectomy (RN) in patients with T3aN0/xM0 renal cell carcinoma (RCC) upstaged from clinical T1 RCC. In this study, we aimed to assess the prognosis difference following PN versus RN in patients with ≤7 cm T3aN0/xM0 RCC.

METHODS

From the Surveillance, Epidemiology, and End Results database, a total of 3196 patients receiving treatment of PN/RN for ≤7 cm T3aN0/xM0 RCC with only extrarenal fat extension in 2010-2017 were identified. An inverse probability of treatment weighting (IPTW)-adjusted cause-specific Cox model with hazard ratio (HR) and 95% confidence interval (CI) was used for overall survival (OS) and cancer-specific survival (CSS) analyses. Sensitivity analysis was based on the propensity score matching of PN and RN groups and from the dataset of 2010-2013.

RESULTS

A total of 872 patients underwent PN, compared with 2324 undergoing RN. After IPTW adjustment, there was no significant difference in preoperative baseline characteristics between the PN and RN cohorts. Patients who underwent RN had worse OS (HR_{IPTW-adjusted} , 1.46; 95% CI, 1.16-1.84; p = 0.001) and comparable CSS (HR_{IPTW-adjusted} , 1.03; 95% CI, 0.64-1.66; p = 0.890) than those receiving PN in all cohorts and subgroups with T3a RCC of ≤4 cm and perinephric fat extension. Further, in patients with 4-7 cm T3a RCC with perinephric-fat invasion and all sizes of T3a RCC with sinus/perisinus fat extension, PN led to comparable OS and CSS. Sensitivity analyses validated these results.

CONCLUSION

PN provides comparable CSS and OS or even better OS than RN for patients with RCC ≤7 cm T3aN0/xM0. Although our study has some limitations, our results indicated that PN might oncologically safe for clinical T1 RCC, even confirmed a pathologically T3a upstaging post-PN.

Ureteral reconstruction for complex strictures: a review of the current literature

PURPOSE

Frequently employed procedures for ureteral reconstruction include balloon dilation, pyeloplasty and ureteral re-implants. However, these procedures do not work for complex ureteral disease. The goal of this literature review is to report on techniques and success rates for the following techniques: buccal graft ureteroplasty, appendiceal interposition, transureteroureterostomy, ileal ureter and autotransplantation.

METHODS

A comprehensive literature search for English-language original and review articles was conducted using PubMed. The following terms were queried: "ureteral reconstruction", "buccal graft", "appendiceal interposition", "ileal ureter", "transureteroureterostomy", "autotransplantation".

RESULTS

Procedures involving the buccal mucosa or appendix offer minimally invasive techniques and low morbidity with good short-term success. Drawbacks to appendiceal interposition include the availability and length of appendix, and 10-20% of patients may have insufficient appendix upon intra-operative assessment. Transureteroureterostomy is typically limited to extensive exonerations due to concerns of injury to the contralateral kidney, even with reported success rates > 90%. Ileal ureter may carry a risk of metabolic acidosis in patients with renal insufficiency along with bowel-related complications. Ileal ureter and autotransplantation are reserved for the most severe cases due to their high morbidity but do offer options for the complex patient.

CONCLUSION

Ureteral stricture disease not amenable to pyeloplasty, ureteroureterostomy or ureteroneocystostomy offers a challenge to urologist. Careful patient selection with pre-operative assessment of renal and bladder is vital to a successful operation with minimal complications.