Survival advantage of partial over radical nephrectomy in patients presenting with localized renal cell carcinoma

Objective assessment of intraoperative skills for robot-assisted partial nephrectomy (RAPN)

RAPN training usually takes place in-vivo and methods vary across countries/institutions. No common system exists to objectively assess trainee capacity to perform RAPN at predetermined performance levels prior to in-vivo practice. The identification of objective performance metrics for RAPN training is a crucial starting point to improve training and surgical outcomes. The authors sought to examine the reliability, construct and discriminative validity of objective intraoperative performance metrics which best characterize the optimal and suboptimal performance of a reference approach for training novice RAPN surgeons. Seven Novice and 9 Experienced RAPN surgeons video recorded one or two independently performed RAPN procedures in the human. The videos were anonymized and two experienced urology surgeons were trained to reliably score RAPN performance, using previously developed metrics. The assessors were blinded to the performing surgeon, hospital and surgeon group. They independently scored surgeon RAPN performance. Novice and Experienced group performance scores were compared for procedure steps completed and errors made. Each group was divided at the median for Total Errors score, and subgroup scores (i.e., Novice HiErrs and LoErrs, Experienced HiErrs and LoErrs) were compared. The mean inter-rater reliability (IRR) for scoring was 0.95 (range 0.84-1). Compared with Novices, Experienced RAPN surgeons made 69% fewer procedural Total Errors. This difference was accentuated when the LoErr Expert RAPN surgeon's performance was compared with the HiErrs Novice RAPN surgeon's performance with an observed 170% fewer Total Errors. GEARS showed poor reliability (Mean IRR = 0.44; range 0.0-0.8), for scoring RAPN surgical performance. The RAPN procedure metrics reliably distinguish Novice and Experienced surgeon performances. They further differentiated performance levels within a group with similar experiences. Reliable and valid metrics will underpin quality-assured novice RAPN surgical training.

International Expert Consensus on Metric-based Characterization of Robot-assisted Partial Nephrectomy

BACKGROUND

Robot-assisted partial nephrectomy (RAPN) training usually takes place in vivo, and methods vary across countries/institutions. No common system exists to objectively assess trainee ability to perform RAPN at predetermined performance levels prior to in vivo practice. The identification of objective performance metrics for RAPN training is a crucial starting point to improve training and surgical outcomes.

OBJECTIVE

We sought to identify objective performance metrics that best characterize a reference approach to RAPN, and obtain face and content validity from procedure experts through a modified Delphi meeting.

DESIGN, SETTING, AND PARTICIPANTS

During a series of online meetings, a core metrics team of three RAPN experts and a senior behavioral scientist performed a detailed task deconstruction of a transperitoneal left-sided RAPN procedure.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Based on published guidelines, manufacturers' instructions, and unedited videos of RAPN, the team identified performance metrics that constitute an optimal approach for training purposes. The metrics were then subjected to an in-person modified international Delphi panel meeting with 19 expert surgeons.

RESULTS AND LIMITATIONS

Eleven procedure phases, with 64 procedure steps, 43 errors, and 39 critical errors, were identified. After the modified Delphi process, the international expert panel added 13 metrics (two steps), six were deleted, and three were modified; 100% panel consensus on the resulting metrics was obtained. Limitations are that the metrics are applicable only to left-sided RAPN cases and some might have been excluded.

CONCLUSIONS

Performance metrics that accurately characterize RAPN procedure were developed by a core group of experts. The metrics were then presented to and endorsed by an international panel of very experienced peers. Reliable and valid metrics underpin effective, quality-assured, structured surgical training for RAPN.

PATIENT SUMMARY

We organize a meeting among robot-assisted partial nephrectomy (RAPN) experts to identify and reach consensus on objective performance metrics for RAPN training. The metrics are a crucial starting point to improve and quality assure surgical training and patients' clinical outcomes.

Robot-assisted versus conventional laparoscopic partial nephrectomy for renal hilar tumors: Parenchymal preservation and functional recovery

OBJECTIVE

To determine whether robot-assisted laparoscopic partial nephrectomy (RALPN) can benefit patients in terms of functional recovery in the treatment of renal hilar tumors compared to conventional laparoscopic partial nephrectomy (CLPN).

METHODS

Between January 2019 and July 2021, patients with hilar tumors who underwent partial nephrectomy (PN) were acquired at our center and were classified into RALPN and CLPN groups. Ipsilateral parenchymal volume (IPV) and glomerular filtration rate (GFR) were determined independently 3-5 days before and 3 months after PN using contrast-enhanced computed tomography and nuclear renal scans. Pearson correlation was used to determine the link between ipsilateral GFR preservation and IPV preserved. Concurrently, multivariable analysis was employed to determine characteristics associated with functional recovery.

RESULTS

A total of 96 patients with hilar tumors were studied, of which 41 received RALPN and 55 received CLPN. Excisional parenchymal volume was 27 and 37 cm³ (p = 0.005) in RALPN and CLPN groups, respectively, and IPV preserved was 77% and 68% (p < 0.001). Furthermore, the ipsilateral GFR preserved was 77.7% and 75.3%, respectively (p = 0.003). On Pearson correlation, ipsilateral GFR preservation was linked with IPV preserved (r = 0.36, p < 0.001). According to a multivariate study, baseline GFR, IPV preserved, and surgical procedures (RALPN vs. CLPN) were significant factors influencing functional recovery.

CONCLUSION

Our study suggests that RALPN, rather than CLPN, can achieve better functional recovery in the treatment of hilar tumors due to its ability to win more IPV preserved. RALPN should be recommended as the first-line treatment for hilar tumors, but randomized controlled trials are required to validate our findings.

Influence of robot-assisted partial nephrectomy on long-term renal function as assessed using DTPA renal scintigraphy

BACKGROUND

The long-term split renal function after robot-assisted partial nephrectomy (RAPN) is yet to be elucidate. This study aimed to assess long-term renal function RAPN, using renal scintigraphy, and to identify clinical factors related to deterioration of renal function on the affected side of the kidney.

PATIENTS AND METHODS

RAPN for small tumors was performed, and split renal function was evaluated using DTPA renal scintigraphy before and 1 year after surgery. Clinical factors (age, sex, body mass index, tumor side, presence of urinary protein, diabetes, hypertension, and dyslipidemia), perioperative factors (renal nephrectomy score [RNS], tumor diameter, overall surgery duration, console time, warm ischemic time, amount of bleeding), and renal function (estimated glomerular filtration rate (eGFR) and glomerular filtration rate (GFR) measured using scintigraphy on both the affected and contralateral kidneys) were analyzed.

RESULTS

Sixty-six patients were included in the study. The median eGFR decreased from 71.9 ml/min to 63.9 ml/min after 1 year (p<.001), accounting for a mean loss of 10.1%. In scintigraphy examination, the median GFR on the affected kidney side decreased from 41.1 ml/min to 33.7 ml/min after 1 year (p<.001), accounting for a mean loss of 16.8%. RNS was significantly associated with renal function. Among RNS factors, the N factor is　associated with renal function after RAPN.

CONCLUSION

RNS, particularly the N factor, possibly influences the long-term deterioration of renal function after RAPN.

Survival benefits analyses of T1a renal cell carcinoma patients treated with microwave ablation

PURPOSE

The individual decision-making reference of Microwave ablation (MWA) for T1a RCC treatment is not clear, and it may not benefit all the patients equally. Therefore, we quantitatively evaluated the distinct survival benefits of patients with T1a RCC stratified by survival predictors.

MATERIALS AND METHODS

A total of 237 patients with T1a RCC who underwent MWA over the last 16 years were retrospectively reviewed for survival benefit analysis. Cox proportional hazard models were used to control for the prognostic variables of OS, CSS, and PFS. Survival rates were calculated using the Kaplan-Meier method and compared by log-rank analysis. Linear extrapolation was used to compute median survival periods.

RESULTS

The OS benefit was significantly dependent on age (HR:2.499, 95% CI: 1.245-5.016, p = 0.010) and age-adjusted Charlson comorbidity index (CCI) score (HR:3.956, 95% CI, 1.409-11.110, p = 0.009). OS in patients aged <75 years or with an age-adjusted CCI score <7 was significantly prolonged (44.68, 65.55 months) compared to OS in patients aged ≥75 years or with CCI score ≥7 (p < 0.001 for both). PFS benefit was significantly dependent on age-adjusted CCI (HR:3.325, 95% CI, 1.390-7.956, p = 0.007), patient type (HR:0.4, 95% CI, 0.214-0.745, p = 0.004), and tumour growth pattern (HR:12.562, 95% CI, 1.552-101.696, p = 0.018). PFS in incipient patients was significantly prolonged (33.75 months) compared to that in the relapsed patients (p = 0.037). Patients with an age-adjusted CCI score <7 or without tumour protruding into the renal pelvis, lived free from recurrence or metastasis (55.69 or 101.61 months) longer than that in patients with an age-adjusted CCI score ≥7 or with tumour protruding into the renal pelvis (p < 0.01 for both). None of the variables was associated with CSS benefit.

CONCLUSIONS

The OS and PFS benefits from MWA were not equal for all T1a RCC patients. Age ≥75 years and age-adjusted CCI ≥ 7 significantly shortened OS. Age-adjusted CCI ≥ 7, relapsed RCC, and RCC protruding into the renal pelvis significantly shortened the PFS period. For a better survival prognosis, appropriate patient triage is still needed.

Outcome of laparoscopic nephron sparing surgery using a Satinsky clamp for hilar control: a trusted tool (SKIMS experience)

Background

Nephron sparing surgery is a well-established surgical procedure for patients with small/bilateral renal masses. During the procedure, hilar control can be achieved by using bulldog clamps individually on the renal vessels, the renal artery alone without clamping the vein, or a laparoscopic Satinsky clamp for en bloc hilar clamping. In our series, we described the outcome of laparoscopic nephron sparing surgery using a Satinsky clamp for hilar control.

Materials and methods

All eligible cases with confirmed diagnosis of a renal mass were advised of nephron sparing surgery. The short-term outcomes were evaluated by warm ischemia time (using a Satinsky clamp especially when CT renal angiography was not available), average blood loss, and length of postoperative hospital stay. The oncological outcome was evaluated by noting the surgical margins of histopathological specimen, local recurrence, and distant metastasis.

Results

Of 30 cases 20 were male. The mean age was 54.25 years. On preoperative evaluation, 24 cases were T1a stage and the rest were 6 T1b stage. Four tumors were located in the upper pole, 4 in the posterior midpole, and 22 in the lower pole. Twenty-six patients had a low complexity score on RENAL scoring (ie, 4-6) and 4 patients a medium complexity score (ie, 7-9). Three patients were converted to open partial nephrectomy because of technical difficulty in intracorporeal suturing and difficulty in achieving hemostasis. Among these 3 patients, 2 patients had posterior base tumors and 1 had a lower polar tumor. Average blood loss was 350 ml, warm ischemia time was 28.46 minutes, and postoperative stay was 4.55 days. Of 30 specimens for histopathology, 23 (76%) were clear cell renal cell carcinoma (RCC), 4 (13%) were papillary RCC, 1 (3.3%) was chromophobe RCC, whereas 2 (6.6%) were benign (oncocytoma). Margins were free of tumors in all the patients with no recurrence in 2 years of follow-up.

Conclusion

Laparoscopic partial nephrectomy by using a Satinsky clamp as a tool for en bloc hilar clamping in the proper axis at the hilum takes care of multiple vessels irrespective of size and number, particularly when renal angiography is not available. This technique of en bloc hilar clamping is quite useful especially in developing countries where robotic facilities are not available. The Satinsky clamp decreases blood loss and intraoperative time.

A comparison of oncologic and functional outcomes in patients with pt3a renal cell carcinoma treated with partial and radical nephrectomy

HYPOTHESIS

Partial Nephrectomy is oncological safe in patients with pT3a RCC.

PURPOSE

To compare the oncological and functional outcomes of patients with pT3a RCC scheduled for PN and RN.

MATERIALS AND METHODS

We retrospectively reviewed patients with pT3a N0 M0 RCC who underwent partial or radical nephrectomy from 2005 to 2016. Perioperative characteristics, including estimated glomerular filtration rate, tumor size, pathological histology, and RENAL nephrometry score, were compared between patients scheduled for partial or radical nephrectomy. We used multivariable Cox proportional hazards regression models to compare overall survival, cancer-specific survival, and recurrence-free survival between planned procedure type.

RESULTS

Of the 589 patients, 369 (63%) and 220 (37%) were scheduled for radical and partial nephrectomy, respectively; 26 (12%) of the scheduled partial nephrectomy cases were intraoperatively converted to radical nephrectomy. After adjusting for tumor size and histology, there were no statistically significant differences in overall survival (hazard ratio 0.66; 95% CI, 0.38-1.13), cancer-specific survival (hazard ratio 0.53; 95% CI, 0.16-1.75), or recurrence-free survival (hazard ratio 0.66; 95% CI, 0.34-1.28) between patients scheduled for partial or radical nephrectomy. Fewer patients scheduled for partial nephrectomy had estimated glomerular filtration rate reductions 3 to 9 months after surgery than patients scheduled for radical nephrectomy.

CONCLUSION

We found no evidence that patients scheduled to undergo partial nephrectomy had poorer oncologic outcomes than patients scheduled to undergo radical nephrectomy. In select patients with pT3a renal cell carcinoma in whom partial nephrectomy is deemed feasible by the surgeon, partial nephrectomy should not be discouraged.

Trends in Renal-Cell Carcinoma Incidence and Mortality in the United States in the Last 2 Decades: A SEER-Based Study

BACKGROUND

Renal-cell carcinoma (RCC) is one of the common malignancies in the United States. RCC incidence and mortality have been changing for many reasons. We performed a thorough investigation of incidence and mortality trends of RCC in the United States using the cell Surveillance, Epidemiology, and End Results (SEER) database.

PATIENTS AND METHODS

The 13 SEER registries were accessed for RCC cases diagnosed between 1992 and 2015. Incidence and mortality were calculated by demographic and tumor characteristics. We calculated annual percentage changes of these rates. Rates were expressed as 100,000 person-years.

RESULTS

A total of 104,584 RCC cases were reviewed, with 47,561 deaths. The overall incidence was 11.281 per 100,000 person-years. Incidence increased by 2.421% per year (95% confidence interval, 2.096, 2.747; P < .001) but later became stable since 2008. However, the incidence of clear-cell subtype continued to increase (1.449%; 95% confidence interval, 0.216, 2.697; P = .024). RCC overall mortality rates have been declining since 2001. However, mortality associated with distant RCC only started to decrease in 2012, with an annual percentage change of 18.270% (95% confidence interval, -28.775, -6.215; P = .006).

CONCLUSION

Despite an overall increase in the incidence of RCC, there has been a recent plateau in RCC incidence rates with a significant decrease in mortality.

Oncological and functional efficacy of nephron-sparing surgery versus radical nephrectomy in renal cell carcinoma stages ≥cT1b: a single institution, matched analysis

Introduction

The purpose of this paper is to compare oncological outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) in renal cell carcinoma (RCC) clinical stages ≥T1b, in a retrospective propensity-score matched cohort of a high-volume, tertiary referral center. This paper also aims to compare renal function and complication rates between groups.

Material and methods

Our single-institution RCC database was queried to select patients with clinical stages defined by tumor size (T), lymph nodes(N), and metastasis (M) scores of T1b-4 N0 M0, that underwent PN or RN between 2000 and 2014. All images of patients that underwent RN were reviewed, and only patients deemed eligible for PN were included. Medical records were reviewed to obtain data on tumor characteristics, comorbidities, renal function, and complications. After propensity score matching, 152 patients (76 per group) were included in the final analysis. Primary outcomes were cancer specific survival (CSS), overall survival (OS), and clinical progression-free survival (CPFS). Secondary outcomes were renal function preservation and post-operative complication rates.

Results

Groups were propensity-score matched. The only parameters that were significantly different between groups were the median follow-up time (RN: 79 months, range 24.1–100.5 vs. PN: 38.5 months, range 20.5–72.1) and a better performance status in the RN group (p = 0.002). The five-year CPFS, CSS, and OS rates were 77.2%, 90.5%, and 86.4%, respectively, in the RN group, and 83.6%, 91.1%, and 82.0%, respectively, in the PN group (p = 0.33, p = 0.55, and p = 0.33, respectively). In the multivariate Cox model, the surgical method was not an independent predictor of CPFS, CSS, or OS. The RN group showed a significantly greater reduction in estimated glomerular filtration rate (RN: 14.1 vs. PN: 5.4 ml/min per 1.73 m²; p <0.03). There was no significant difference in complication rates between the two groups (p = 0.3). The main limitations of this study were its retrospective design and the medium-term follow-up.

Conclusions

Our results demonstrated the efficacy and safety of PN in patients with RCC in clinical stages ≥T1b. We observed no significant difference in oncological outcomes between the PN and RN groups at medium-term follow ups. The surgical method did not influence these outcomes. Renal function was preserved significantly more frequently in the PN than in the RN group, but the groups had similar complication rates.

These findings suggested that PN could be considered an oncologically safe procedure for treating large RCC tumors; thus, PN should always be considered, when technically feasible, regardless of tumor stage.

Partial nephrectomy for T3aN0M0 renal cell carcinoma: shall we step forward?

Objectives:

To evaluate the prognosis of non-metastatic T3a renal cell carcinoma (RCC) with partial nephrectomy (PN).

Patients and Methods:

We retrospectively evaluated 125 patients with non-metastatic T3a RCC. Patients undergoing PN and radical nephrectomy (RN) were strictly matched by clinic-pathologic characteristics. Log-rank test and Cox regression model were used for univariate and multivariate analysis.

Results:

18 pair patients were matched and the median follow-up was 35.5 (10-86) months. PN patients had a higher postoperative eGFR than RN patients (P=0.034). Cancer-specific survival (CSS) and recurrence-free survival (RFS) did not differ between two groups (P=0.305 and P=0.524). On multivariate analysis, CSS decreased with positive surgical margin and anemia (both P <0.01) and RFS decreased with Furhman grade, positive surgical margin, and anemia (all P<0.01).

Conclusions:

For patients with non-metastatic pT3a RCC, PN may be a possible option for similar oncology outcomes and better renal function.

Robot-assisted Partial Nephrectomy: 5-yr Oncological Outcomes at a Single European Tertiary Cancer Center

BACKGROUND

Nowadays, there is a debate about which surgical treatment should be best for clinical T1 renal tumors. If the oncological outcomes are considered, there are many open and laparoscopic series published. As far as robotic series are concerned, only a few of them report 5-yr oncological outcomes.

OBJECTIVE

The aim of this study was to analyze robot-assisted partial nephrectomy (RAPN) midterm oncological outcomes achieved in a tertiary robotic reference center.

DESIGN, SETTING, AND PARTICIPANTS

Between April 2009 and September 2013, 123 consecutive patients with clinical T1-stage renal masses underwent RAPN in our tertiary cancer center. Inclusion criteria were as follows: pathologically confirmed renal cell carcinomas (RCCs) and follow-up for >12 mo. Eighteen patients were excluded due to follow-up of <12 mo and 15 due to benign final pathology. Median follow-up was 59 mo (interquartile range 44-73 mo). Patients were followed according to guideline recommendations and institutional protocol.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Outcomes were measured by time to disease progression, overall survival, or time to cancer-specific death. Kaplan-Meier method was used to estimate survival; log-rank tests were applied for pair-wise comparison of survival.

RESULTS AND LIMITATIONS

From the 90 patients included, 66 (73.3%) had T1a, 12 (13.3%) T1b, three (3.3%) T2a, and nine (10%) T3a tumors. Predominant histological type was clear cell carcinoma: 67 (74.5%). Fuhrmann grade 1 and 2 was found in 73.3% of all malignant tumors. Two patients (2.2%) had positive surgical margins, and complication rate was 17.8%. Relapse rate was 7.7%, including two cases (2.2%) of local recurrences and five (5.5%) distant metastasis. Five-year disease-free survival was 90.9%, 5-yr cancer-specific survival was 97.5%, and 5-yr overall survival was 95.1%.

CONCLUSIONS

Midterm oncological outcomes after RAPN for localized RCCs (predominantly T1a tumors of low anatomic complexity) were shown to be good, adding significant evidence to support the oncological efficacy and safety of RAPN for the treatment of this type of tumors.

PATIENT SUMMARY

Robot-assisted partial nephrectomy seems to be the most promising minimally invasive approach in the treatment of renal masses suitable for organ-sparing surgery as midterm (5 yr) oncological outcomes are excellent.

Nephron Sparing Surgery Has Better Oncologic Outcomes Than Extirpative Nephrectomy in T1a but Not in T1b or T2 Stage Renal Cell Carcinoma

BACKGROUND The aim of this study was to investigate the benefit of nephron sparing surgery (NSS) compared with extirpative nephrectomy in different tumor stages of renal cell carcinoma. MATERIAL AND METHODS We reviewed the Surveillance, Epidemiology and End Results (SEER) database for NSS and extirpative nephrectomy in localized (stages T1-2N0M0) renal cell carcinoma diagnosed after 2004. We used the variable screening function of the SEER database to identified 55,947 cases that met inclusion and exclusion criteria for survival analysis. Overall mortality and cancer-specific mortality were the primary index outcomes. Stratification analysis was done by T stage subgroups. We also performed survival analysis using propensity score analysis, and changed the survival model to the competing-risk model for cancer-specific mortality analysis. RESULTS Overall, NSS significantly decreased the risk of overall mortality (HR 0.717, 0.668-0.769) and cancer-specific mortality (HR 0.604, 0.525-0.694) when compared to extirpative nephrectomy. In subgroup analysis, NSS had a lower overall mortality risk and cancer-specific mortality compared to extirpative nephrectomy only for T1a stage renal cell carcinoma (HR 0.654, 0.599-0.714, p<0.01 and HR 0.554, 0.458-0.670, p<0.01, respectively), but not for T1b or T2 stage. The propensity score analysis, which included standardized mortality ratio weight adjustment, showed the same results. Additionally, for cancer-specific mortality, a competing-risk model gave the exactly same outcome. CONCLUSIONS Compared to extirpative nephrectomy, NSS provided superior overall survival and cancer-specific survival for localized renal cell carcinoma only in T1a stage, not in T1b or T2 stage. NSS should be recommended when the surgery is possible. Further prospective study is needed to confirm this result.

Image-guided ablation of renal cell carcinoma

This review article aims to provide an overview of image-guided ablation of renal cell carcinoma (RCC) since it was first introduced in 1998. This will cover the background and rationale behind its development; an overview of the evidence for current thermal technology, such as heat-based, e.g., radiofrequency ablation (RFA), microwave ablation (MWA), and cold-based energies, e.g., cryoablation used; and summarise the published evidence regarding its treatment efficacy and oncological outcome. In addition, it aims to provide an insight into the potential role of the new non-thermal ablative technology, e.g., irreversible electroporation (IRE)/Nanoknife in image-guided ablation of RCC, as well as areas of challenge that will require further research and clinical evaluation to ensure delivery of a quality patient-centred interventional oncology (IO) service in image-guided ablation of RCC.

Nephron Sparing for Renal Cell Carcinoma: Whenever Possible?

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

Comparison of oncologic outcomes between partial and radical nephrectomy for localized renal cell carcinoma: A systematic review and meta-analysis

To date, there remain uncertainties over the oncological outcomes for partial and radical nephrectomy of localized renal cell carcinoma (RCC). A systematic review and meta-analysis was performed. Eligible studies were retrieved from PubMed, Embase, Cochrane Library and Web of Science databases. The endpoints of oncologic outcomes included overall survival (OS), cancer-specific survival (CSS) and recurrence-free survival (RFS). Multivariable adjusted hazard ratios (HRs) were used to evaluate each endpoint. We used the Newcastle-Ottawa scale to assess risk of bias. Fourteen cohort studies of low to moderate risk of bias involving 28,764 patients were included. Adjusted variables and follow-up length varied between studies. The results showed that patients with localized RCC who underwent partial nephrectomy (PN) had a superior OS (HR: 0.81, 95% confidence interval (CI): 0.74-0.89; P < 0.001) compared with those underwent radical nephrectomy (RN). However, the CSS (HR: 0.85, 95% CI: 0.73-1.01; P = 0.060) and RFS (HR: 0.66, 95% CI: 0.34-1.31; P = 0.239) seem to be similar for patients underwent PN and RN. Most of subgroup analyses according to year of publication, patient population, geographic region and NOS score did not alter the direction of results. PN for localized RCC is associated with better OS, similar CSS and RFS compared with RN based on observational data with low to moderate risk of bias. Methodological limitations of the observational studies included should be considered while interpreting these results.

Nephron Sparing Surgery Associated With Better Survival Than Radical Nephrectomy in Patients Treated for Unforeseen Benign Renal Tumors

OBJECTIVE

To evaluate the role of the surgical technique used for the treatment of benign renal tumors, with regard to renal function and overall survival (OS) in patients without cancer-related mortality.

PATIENTS AND METHODS

The study included 506 patients, mean age of 63.3 years, with histologically proven benign renal lesions originating from 5 European centers. Retrospective data from each hospital were retrieved and merged into a common database for analyses. OS, American Society of Anesthesiology score, and renal functions were measured in relation to surgical technique. The Mann-Witney U-test, the paired t-test, and Cox's multivariate analysis were used.

RESULTS

Patients treated with radical nephrectomy had significantly reduced renal function postoperatively compared with nephron sparing surgery (NSS). OS was significantly reduced after radical nephrectomy compared with NSS (P = .012), a survival difference that remained significant [hazard ratio (HR) 0.042, 95% confidence interval (CI) 0.221-0.972, P = .042] in multivariate analysis, together with age at diagnosis (HR 1.065, 95% CI 1.026-1.106, P = .001) and American Society of Anesthesiology score (HR 2.361, 95% CI 1.261-4.419, P = .007). Also renal function assessed by estimated glomerular filtration rate significantly correlated to survival in univariate analysis, but did not remain independent after multivariate analysis. Oncocytoma was the most frequent benign lesion, followed by angiomyolipoma.

CONCLUSION

The present study in patients with benign renal tumors shows that the remaining renal function and OS correspond to the choice of surgical procedure. Our results support the recommendation to perform NSS whenever possible when surgery is performed for patients with renal masses. The limitations of the study are the retrospective design and the selection bias for the surgical approach.

Preoperative Neutrophil to Lymphocyte Ratio as a Prognostic Factor in Patients with Non-metastatic Renal Cell Carcinoma

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) is a strong predictor of mortality in patients with colorectal, lung, gastric cancer, pancreatic and metastatic renal cell carcinoma. We here evaluated whether preoperative NLR is an independent prognostic factor for non-metastatic renal cell carcinoma (RCC).

MATERIALS AND METHODS

Data from 327 patients who underwent curative or palliative nephrectomy were evaluated retrospectively. In preoperative blood routine examination, neutrophils and lymphocytes were obtained. The predictive value of NLR for non-metastatic RCC was analyzed.

RESULTS

The NLR of 327 patients was 2.72±2.25. NLR <1.7 and NLR ≥1.7 were classified as low and high NLR groups, respectively. Chi-square test showed that the preoperative NLR was significantly correlated with the tumor size (P=0.025), but not with the histological subtype (P=0.095)and the pT stage (P=0.283). Overall survival (OS) and disease-free survival (DFS) were assessed using the Kaplan-Meier method. Effects of NLR on OS (P=0.007) and DFS (P=0.011) were significant. To evaluate the independent prognostic significance of NLR, multivariate COX regression models were applied and identified increased NLR as an independent prognostic factor for OS (P=0.015), and DFS (P=0.019).

CONCLUSIONS

Regarding patient survival, an increased NLR represented an independent risk factor, which might reflect a higher risk for severe cardiovascular and other comorbidities. An elevated blood NLR may be a biomarker of poor OS and DFS in patients with non-metastatic RCC.

Assessment of Surgical Outcomes of the Non-renorrhaphy Technique in Open Partial Nephrectomy for ≥T1b Renal Tumors

OBJECTIVE

To assess surgical outcomes between the non-renorrhaphy and renorrhaphy techniques in open partial nephrectomy for ≥T1b renal tumors using volumetric studies.

METHODS

We retrospectively analyzed the records of 91 patients with normal contralateral kidneys who underwent both open partial nephrectomy for ≥T1b renal tumors and pre- and postoperative enhanced computed tomography between 2010 and 2014. Volumetric studies to assess vascularized parenchymal volume of the operated kidney were performed within 2 months preoperatively and 6 months postoperatively. Using the non-renorrhaphy technique, we coagulated hemorrhagic areas on the surface of the renal parenchyma by monopolar soft coagulation, while a TachoSil tissue-sealing sheet was placed on the resected bed.

RESULTS

A total of 50 patients underwent renorrhaphy and 41 patients underwent non-renorrhaphy. Patient backgrounds and R.E.N.A.L. nephrometry scores were not significantly different between the two groups. Cold ischemia time was significantly longer in the renorrhaphy than that in the non-renorrhaphy (52 vs 42 minutes, P = .0162). However, significant differences were not observed in the preservation rate of the vascularized parenchymal mass in the operated kidney (renorrhaphy, 71%; non-renorrhaphy, 70%; P = .5054) and global kidney function (renorrhaphy, 88%; non-renorrhaphy, 90%; P = .3653) between the two groups. Renal artery pseudoaneurysm occurred in 2 cases in both groups. Urinary fistula tended to occur more frequently in non-renorrhaphy (2 cases) than in renorrhaphy (5 cases), though this difference was not statistically significant (P = .237).

CONCLUSION

The non-renorrhaphy technique failed to show a benefit in the preservation of vascularized parenchymal mass of the operated kidney and global renal function for ≥T1b renal tumors compared to the renorrhaphy technique.

Comparison of survival rates in stage 1 renal cell carcinoma between partial nephrectomy and radical nephrectomy patients according to age distribution: a propensity score matching study

OBJECTIVE

To assess differences in overall survival (OS) between patients receiving partial nephrectomy (PN) and radical nephrectomy (RN) for stage 1 renal cell carcinoma (RCC) according to age distribution, as the survival advantage of PN vs RN has been unclear owing to conflicting data.

PATIENTS AND METHODS

We studied 952 patients with stage 1 RCC who underwent either PN or RN. Patients were divided into three groups according to age: Group 1 (≤54 years), Group 2 (55-64 years), and Group 3 (≥65 years). Patient variables including age, body mass index, sex, presence of hypertension (HT) and/or diabetes mellitus (DM), performance status, tumour size, pathological diagnosis, nuclear grade, and preoperative estimated glomerular filtration rate (eGFR), were adjusted using 1:1 propensity score matching between PN and RN.

RESULTS

Group 1 included 66 matched patients; Group 2, 72; and Group 3, 70. Group 1 tended to have higher preoperative eGFR values and lower rates of HT and DM compared with Groups 2 and 3. Postoperative eGFR dropped by 11-13% in PN patients and by 34-36% in RN patients. In Group 3, PN patients had longer OS than RN patients (5-year OS: PN 96%, RN 81%, P = 0.043); however, there was no significant difference in Group 1 (5-year OS: PN 100%, RN 93%, P = 0.302) or Group 2 (5-year OS: PN 94%, RN 87%, P = 0.358).

CONCLUSIONS

Only the oldest group of patients showed significantly better OS for PN compared with RN; however, we still recommend PN in young patients.

[Experience in nephron-sparing surgery in patients with small renal tumors]

BACKGROUND

Nephron -sparing surgery is currently the treatment of choice for surgical removal of solid renal tumours smaller than 7 cm, in the case of a solitary kidney, bilateral renal tumours or the presence of chronic renal failure.

MATERIAL AND METHODS

An observational, descriptive, retrospective and cross-sectional study was conducted. The variables evaluated were: age at diagnosis, gender, intraoperative blood loss, operative time, preoperative tumour size, hospital stay, pathology report, pTNM classification, Fuhrman nuclear grade, pre- and post-operative creatinine, monitoring for cancer. All were analysed using SPSS v 22.

RESULTS

The study included 28 patients, 14 male and 14 women, with a mean age 52.3 years. The approach was lumbotomy in all patients. The mean hospital stay was 4.1 days. Mean perioperative bleeding loss was 380.3 ml. The mean preoperative creatinine was 0.96 mg/dl, with a post-operative mean of 1.12 mg/dl. Histopathology reported, 23 clear cell tumours, 2 angiomyolipomas, 2 oncocytomas, and 1 haemorrhagic cyst. Tumour staging was performed on 14 patients, with 13 patients T1bN0M0, and 1 patient T2aN0M0. In clear cell tumours, Fuhrman nuclear grade 2 was present in 16 patients and 7 patients were Fuhrman grade 3.

CONCLUSION

Nephron sparing surgery is the choice procedure of choice in patients with small renal tumours, with good functional results without significant alteration in renal function. Outcome is optimal, with a low incidence of complications.