Predictors of postoperative renal functional damage after nephron-sparing surgery

Overview of clinical management for older patients with renal cell carcinoma

The rapidly increasing pool of older patients being diagnosed with and surviving their cancer is creating many challenges. Regarding localized renal cell carcinoma, surgery is considered as gold standard treatment options even in older men, whereas active surveillance and ablation therapy are alternative options for a proportion of these patients. With regard to advanced disease, anti-vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) and immune check point inhibitor are standard treatment modalities, although treatment choice from multiple regimens and prevention of adverse events need to be considered. Better assessment techniques, such as comprehensive geriatric assessment to meet the unique needs of older patients, are a central focus in the delivery of high-quality geriatric oncology care. Through this process, shared decision-making should be adopted in clinical care to achieve optimal goals of care that reflect patient and caregiver hopes, needs and preferences. It is necessary to continue investigating oncological outcomes and complications associated with treatment in this population to ensure appropriate cancer care. In this narrative review, we completed a literature review of the various treatments for renal cell carcinoma in older patients that aimed to identify the current evidence related to the full range of the treatments including active surveillance, surgery, ablation therapy and systemic therapy. Prospectively designed studies and studies regarding geriatric assessment were preferentially added as references. Our goals were to summarize the real-world evidence and provide a decision framework that guides better cancer practices for older patients with renal cell carcinoma.

Parallel comparison of R.E.N.A.L., PADUA, and C-index scoring systems in predicting outcomes after partial nephrectomy: A systematic review and meta-analysis

Objective

To parallelly compare the applicability of the radius, exophytic/endophytic, nearness, anterior/posterior, location nephrometry score (R.E.N.A.L.), the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA), and the centrality index (C‐index) scoring systems in predicting clinical outcomes after partial nephrectomy (PN).

Methods

We searched EMBASE, PubMed, Ovid, and Web of Science to perform a meta‐analysis examining the correlation coefficients between three nephrometry scores (NSs) and warm ischemia time (WIT), estimated blood loss (EBL), operation time (OT), length of stay (LOS), and absolute change in eGFR (ACE) up to 25 January 2021.

Results

In total, 13 studies including 1496 patients met the criteria for further analysis. Overall, all scoring systems had statistically significant correlations with the WIT, EBL, OT, ACE and LOS and ACE, except for the correlation between PADUA and LOS (r = 0.16 [−0.00, 0.31], p > 0.05). The C‐index had the strongest correlation with WIT (r = −0.35 [−0.43, −0.26], p < 0.05) and ACE (r = −0.29 [−0.48, −0.10], p < 0.05). Weak correlations were observed between OT as well as EBL and each scoring system. Publication bias was observed in PADUA score predicting ACE (p = 0.04) and high heterogeneity was found in some of our results.

Conclusion

Until now, this is the first meta‐analysis that parallelly compares these three scoring systems in predicting outcomes after PN. We found that all NSs showed a statistically significant correlation with WIT, EBL, OT, and ACE. Moreover, the C‐index scoring system is the best predictor of WIT and ACE. Due to the existence of publication bias and high heterogeneity, more well‐designed and large‐scale studies are warranted for validation.

To our knowledge, this is the first meta‐analysis that parallelly compares these three scoring systems in predicting outcomes after PN. Overall, three scoring systems were significantly correlated with WIT, EBL, OT and ACE. Moreover, the C‐index scoring system outperformed R.E.N.A.L. and PADUA scoring systems in WIT and ACE.

Predicting trifecta outcomes after robot-assisted nephron-sparing surgery: Beyond the nephrometry score

Purpose

RENAL nephrometry score (RNS) was devised for deciding the approach for renal tumors. It is increasingly used in predicting perioperative outcomes with variable results. The actual difficulty encountered during surgery depends on a number of other variables. The main purpose of this prospective study was to identify these variables which are not addressed by current RNS.

Materials and Methods

Forty-nine patients undergoing robotic nephron sparing surgery from January 2015 onward were included. RNS was calculated from the imaging. Operating surgeon rated each surgery on a Likert scale of 0–4 after the completion of the procedure. The questionnaire was pre-validated in 5 cases before administration. The correlation between the surgeon rating and RNS with perioperative parameters and trifecta outcomes were calculated.

Results

Forty-seven percent surgeries were rated easy, and 53.0% were rated as difficult. Surgeries for hilar, posterior location and presence of supernumerary vessels were found to be the a cause of difficulty. Trifecta outcomes were achieved in 37/49 patients (75.5%). The mean rating was 2.580±0.900 in trifecta negative patients while it was 1.410±0.832 in trifecta positive patient (p<0.0001). Surgeon's rating correlated positively with trifecta outcomes (likelihood ratio=15.75, p=0.006).

Conclusions

The RNS remained a useful tool for determining renal tumor complexity. The intraoperative difficulty faced by the surgeon can be rated which can better predict perioperative trifecta outcomes. A useful predicting tool can be developed using the two parameters (RNS and surgeon rated difficulty).

Comparison of RENAL, PADUA, and C-index scoring systems in predicting perioperative outcomes after nephron sparing surgery

Introduction and Objective

The RENAL, PADUA and centrality index (C-index) nephrometry scoring systems (SS) have been individually evaluated for their role in predicting trifecta outcomes after nephron-sparing surgery (NSS). However, there is little data on their comparative superiority. The present study was designed to evaluate the predictive value of three SS and to assess interobserver reliability.

Materials and Methods

Fifty patients undergoing NSS at our center between January 2014 and April 2016 were included in the study. The demographic details were noted. Images (computed tomography [CT] scans or magnetic resonance imaging) were reviewed by a urologist and a radiologist independently and RENAL, PADUA, and C-index were calculated. The correlation between these scoring system and trifecta outcomes were calculated.

Results

The RENAL and PADUA score did not correlate with any of the perioperative parameters. However, C-index had a significant correlation with operative time (OT) (P = 0.02) and trifecta outcomes (P < 0.05). There was an excellent concordance between the two observers in scoring the RENAL score (α = 0.915; intraclass correlation coefficient [ICC] = 0.814) and PADUA score (α = 0.816; ICC = 0.689 [P < 0.001]). There was lesser although acceptable concordance in the calculation of C-index (ICC -0.552; α -0.711).

Conclusions

There is good correlation among all the 3 SS. C-index has lower reproducibility due to difficult mathematical calculation but correlated best with trifecta outcomes.