Comparison of aggressiveness in central versus peripheral T1a clear-cell renal cell carcinoma

PURPOSE

This study aimed to estimate the difference between peripheral and central small renal lesions in terms of their oncologic potential.

METHODS

Cross-sectional retrospective analysis of patients with small renal masses (T1a) who underwent surgical treatment between January 2008 and July 2019 at the affiliated hospital. Only patients with ccRCC pathology were included. Cases were divided into 2 groups depending on tumor location (central or peripheral) based on the R.E.N.A.L and local nephrometry scoring. Presence of nodal involvement, distant metastases, ISUP grade and endophytic growth were defined as aggressiveness predictors. Statistical analyses was performed using a standard statistical software (IBM SPPS Statistics Ver. 22), with P < 0.05 considered statistically significant. Associations between tumor location and Fuhrman grade, exo-/endophytic growth, TNM classification, and type of operation were tested using the Pearson χ² test and 1-way ANOVA test.

RESULTS

Patients with centrally located tumors had a higher incidence of clinical and pathological lymph node involvement (P = 0.02, χ2 = 5.1). Patients in both groups had an equal number of distant metastases at the time of diagnosis (P = 0.3, χ2 = 0.8). The operation time was significantly longer in patients with central lesions, which obviously showed higher tumor complexity in this group (P < 0.005). Pathological evaluation revealed differences between ISUP grades in both groups (P < 0.005, χ2 = 29.9). Central masses were characterized by higher aggressiveness, indicating a worse prognosis. Furthermore, the cases in the first group were more often endophytic (P = 0.03, χ2 = 0.9). Nevertheless, this did not affect the surgical strategy in most cases with a tendency toward partial nephrectomy. Eventually, organ-sparing treatment was preferable in both groups (P = 0.13, χ2 = 2.29).

CONCLUSION

Centrally located kidney cancer has showed in present study a higher incidence of high ISUP grade, regional nodal involvement and endophytic growth type. Endophytic growth type was associated with worse ISUP grading. Distribution of ISUP grade was not age depended, thus showing no difference by this criterion, when comparing different age groups. Higher ISUP grade was strongly associated with presence of distant metastases in T1a kidney tumors. Further analysis is needed to investigate aggressiveness of centrally located T1a RCC, as it may influence current conservative management options.

How far has robot-assisted partial nephrectomy reached?

Nephron-sparing surgery is the standard treatment for small renal mass (SRM). Nephron-sparing surgery has evolved from an open to a minimally invasive technique. Robot-assisted partial nephrectomy (RAPN) is the latest technique in this field and is reported to be safe and feasible, showing oncologically and functionally superior or compatible results compared with open and laparoscopic partial nephrectomy for SRM. This is not limited to only SRM but also applies to large and complex renal masses and other challenging situations. RAPN showed good oncological and functional outcomes for ≥clinical T2 renal tumors, complex renal masses (PADUA score ≥10, RENAL score ≥10), hilar renal tumors, and multiple renal tumors. In addition, the outcomes of RAPN in these challenging cases were not inferior to those in conventional cases. RAPN could also be applied to a number of challenging cases in which the open technique was considered first. RAPN showed good results in patients with a solitary kidney, horseshoe kidney, and in repeat surgeries. Furthermore, RAPN could be safely performed on obese, elderly, and pediatric patients. Finally, this review evaluates efficiency and utility of RAPN based on the results of challenging cases of renal masses and to project the future of RAPN.

Trifecta and pentafecta outcomes following robot-assisted partial nephrectomy for hilar versus nonhilar tumors: A propensity-matched analysis

Introduction

Hilar tumors are a unique subset of complex renal masses posing a potential surgical challenge during partial nephrectomy. The outcomes of hilar masses have not been compared to non-hilar renal masses of similar RENAL nephrometry score (RNS). In this study, we analyzed the outcomes of hilar versus nonhilar masses after a propensity score matching.

Methods

Prospectively maintained database of patients who underwent robot assisted PN between November 2014 and December 2018 was abstracted for hilar and nonhilar tumors. We performed propensity matching for baseline variables such as age, sex, body mass index, comorbidities, preoperative glomerular filtration rate, and RNS for each patient on the basis of propensity scores.

Results

We included 48 patients with hilar tumors and 153 with nonhilar tumors. On propensity matching, 41 patients were included in each group. The mean operative time (162.4 ± 48.9 min vs. 144.1 ± 38.8 min, P = 0.48), warm ischemia time (29.0 ± 8.8 min vs. 24.4 ± 8.2 min, P = 0.12), and the estimated blood loss (201.8 ± 184.7 ml vs. 150.6 ± 160.5 ml, P = 0.37) were not significantly different between the hilar and the nonhilar groups. Trifecta was achieved in only 14/41 (34.1%) of the patients in the hilar group as compared to 24/41 (58.5%) in the nonhilar group (P = 0.027). Logistic regression analysis identified that hilar location of the tumors was not an independent predictor of overall complications (OR 6.37, confidence interval [CI] 0.5-69.4, P = 0.4), trifecta (OR 0.38, CI 0.14-1.0, P = 0.051), and pentafecta outcomes (OR 0.4, CI 0.1-1.51, P = 0.17).

Conclusions

Hilar location was associated with poorer trifecta outcomes compared to the nonhilar tumors. However, hilar location per se was not an independent predictor of overall complications and trifecta and pentafecta outcomes.

Open partial nephrectomy with kidney split: Effective surgical approach to resect completely endophytic tumors

OBJECTIVES

To review perioperative, renal functional, and oncological outcomes of the kidney split technique in performing partial nephrectomy (PN) to resect completely endophytic renal tumors.

METHODS

All consecutive patients who underwent open PN with kidney split between 2015 and 2019 at our institution were included. In this approach the kidney is incised along Brodel's line in an avascular plane to locate and then resect the endophytic tumor. Clinicopathologic data, perioperative metrics, complications, renal function, recurrence, and mortality were analyzed using descriptive statistics.

RESULTS

Forty-two open PN with kidney split were performed in 40 patients. No patients required conversion to radical nephrectomy. Most tumors were pT1a renal cell carcinoma (76%), with no recurrences or deaths after a median follow-up of 15 months. All patients had tumors of moderate or high complexity by R.E.N.A.L. nephrometry score. Median cold ischemia time, operative time, estimated blood loss, and inpatient length-of-stay were 34 minutes, 152 minutes, 225 ml, and 2 days, respectively. No patients experienced any Clavien-Dindo grade 4 or 5 complications. Postoperative estimated glomerular filtration rate (eGFR) at last follow-up was >30 ml/min/1.73m² in all but one patient, and no patients required dialysis.

CONCLUSIONS

The kidney split represents an effective PN technique to resect complex, endophytic renal tumors. In our experience, this technique affords acceptable perioperative outcomes, preserved renal function, and no short-term recurrences or mortality events. Our series highlights the importance of adapting classical surgical techniques, using cold ischemia, and relying on preoperative and intraoperative ultrasonography to effectively guide this complex kidney-sparing operation.

The prognostic role of preoperative serum albumin/globulin ratio in patients with non-metastatic renal cell carcinoma undergoing partial or radical nephrectomy

This multi-institutional study sought to clarify the association between the preoperative serum albumin/globulin ratio (AGR) and the prognosis of renal cell carcinoma (RCC) in a large cohort. This study encompassed eight institutions and 2,970 non-metastatic RCC patients who underwent a radical or partial nephrectomy from the Korean RCC (KORCC) database. A low AGR (1,143 patients; 38.5%) was defined as a preoperative AGR of less than 1.47 and a high AGR (1,827 patients; 61.5%) was defined as that 1.47 or greater. In the low AGR group, older age, female gender, the incidence of symptom presentation when diagnosed, diabetes, and hypertension was higher than in the high AGR group. Patients with low AGRs showed more progressive tumor stages with higher Fuhrman nuclear grades (all P-values < 0.05). Patients in the low AGR group had a significantly lower overall survival rate (OS) and recurrence-free survival rate (RFS) in the Kaplan-Meier curves (all P-values < 0.05). AGR was an independent prognostic factor for predicting the OS and RFS in the multivariate analysis (all P-values < 0.05). The preoperative AGR is approachable and economical to use clinically for estimating the prognosis of RCC patients treated with surgery.

Head to Head Impact of Margin, Ischemia, Complications, Score Versus a Novel Trifecta Score on Oncologic and Functional Outcomes After Robotic-assisted Partial Nephrectomy: Results of a Multicenter Series

BACKGROUND

There is a paucity of data describing the ability of margin, ischemia, complications, score (MIC) and trifecta in predicting long-term outcomes of robotic-assisted partial nephrectomy (RAPN).

OBJECTIVE

To compare a novel trifecta (negative margins, no significant complications, and perioperative estimated glomerular filtration rate [eGFR] decrease ≤30%) versus standard MIC as predictors of oncologic and functional results in a large series of RAPNs.

DESIGN, SETTING, AND PARTICIPANTS

Between 2009 and 2019, a multicenter dataset was queried for patients with nonmetastatic renal masses who underwent RAPN at eight participating institutions.

INTERVENTION

RAPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

MIC and trifecta achievement were determined for the overall cohort and a subgroup undergoing off-clamp RAPN (ocRAPN), respectively. The overall survival (OS), recurrence-free survival (RFS), and new onset of end-stage renal disease (ESRD; defined as eGFR <30 ml/min) probabilities were assessed by the Kaplan-Meier method. Cox regression analyses were used to identify predictors of OS, RFS, and ESRD. For all analyses, two-sided p < 0.05 was considered significant.

RESULTS AND LIMITATIONS

Out of 1807 patients, MIC and trifecta were achieved in 71.1% (n = 1285) and 82.6% (n = 1492), respectively, and once restricted to the ocRAPN cohort, in 95.6% (n = 625) and 81.6% (n = 534), respectively. On Kaplan-Meier analysis, both MIC and trifecta achievement predicted higher OS and lower ESRD probabilities (all p < 0.014), while only trifecta achievement was a predictor of RFS probabilities (p = 0.009). On multivariable Cox regression, MIC did not predict any of the endpoints independently, while trifecta achievement was an independent predictor of higher OS (hazard ratio [HR] 0.4, 95% confidence interval [CI] 0.18-0.86; p = 0.019) and lower ESRD development probabilities (HR 0.32, 95% CI 0.15-0.72; p = 0.005).

CONCLUSIONS

Trifecta, initially described as comprehensive measures of perioperative outcomes, needs to stand the test of time. Compared with MIC, the recent trifecta was an independent predictor of clinically significant endpoints, namely, survival and ESRD development probabilities.

PATIENT SUMMARY

Our novel trifecta represents a reliable method for estimating survival and development of end-stage renal disease after robotic-assisted partial nephrectomy.

Contact with renal sinus is associated with poor prognosis in surgically treated pT1 clear cell renal cell carcinoma

OBJECTIVE

To investigate the prognostic significance of contact with the renal sinus in patients with clear cell renal cell carcinoma.

METHODS

A total of 787 pT1N0M0 clear cell renal cell carcinoma patients who had undergone radical or partial nephrectomy were reviewed retrospectively. A tumor in contact with the renal sinus was defined as a tumor radiologically attached to the renal sinus. Metastatic-free survival rates were analyzed in the total and propensity score-matched cohorts. A risk score model for metastasis after surgery was developed.

RESULTS

Of the 787 patients, 411 (52.2%) had tumors in contact with renal sinus. The contact with renal sinus group showed poorer metastatic-free survival in both total and matched cohorts. In multivariate analysis, contact with renal sinus was an independent prognostic factor of metastasis, as well as Fuhrman grade, microvascular invasion and age. The scoring model likewise consisted of Fuhrman grade, microvascular invasion, age and contact with renal sinus. Metastasis-free survival curves were clearly stratified according to risk, with 5-year metastasis-free survival rates of 95.7% and 65.2% in the low- and high-risk groups, respectively (P < 0.001).

CONCLUSIONS

Contact with the renal sinus is a significant risk factor for metastasis in T1 clear cell renal cell carcinoma after surgery. More intensive follow up should be recommended for patients with renal cell carcinoma that is in contact with the renal sinus.

Navigation of Intelligent/Interactive Qualitative and Quantitative Analysis Three-Dimensional Reconstruction Technique in Laparoscopic or Robotic Assisted Partial Nephrectomy for Renal Hilar Tumors

Purpose: To evaluate the feasibility and effectiveness of the navigation of intelligent/interactive qualitative and quantitative analysis (IQQA) three-dimensional (3D) reconstruction technique in laparoscopic or robotic assisted partial nephrectomy (LPN or RAPN) for renal hilar tumors. Patients and Methods: The study retrospectively reviewed 26 patients with hilar tumors from February 2016 to February 2018. IQQA 3D reconstruction technique was applied for the purpose of navigation and resection of the tumors. Relevant clinical parameters and surgical outcomes were recorded. Results: All 26 LPN or RAPN were effectively completed without conversion to a hand-assisted or an open approach. Under the navigation of IQQA, all tumors were found precisely at the first time during surgeries. The mean operative time was 142 minutes (142 ± 35), with a mean warm ischemia time of 24.3 minutes (24.3 ± 9.5). The estimated blood loss was 156 mL (156 ± 112). No intraoperative complications occurred. Two patients suffered from postoperative complications. All patients had negative margins on the final pathological examination. At a mean follow-up period of 3 months, the mean glomerular filtration rate is 22.5 mL/min (22.5 ± 7.1) without tumor recurrence. Conclusions: With peculiar features, such as accurate location, complete resection, and fewer perioperative complications, the navigation of IQQA 3D reconstruction technique in partial nephrectomy represents a safe and effective procedure for hilar tumors.

Magnetic resonance imaging (MRI) of the renal sinus

This article presents methods to improve MR imaging approach of disorders of the renal sinus which are relatively uncommon and can be technically challenging. Multi-planar Single-shot T2-weighted (T2W) Fast Spin-Echo sequences are recommended to optimally assess anatomic relations of disease. Multi-planar 3D-T1W Gradient Recalled Echo imaging before and after Gadolinium administration depicts the presence and type of enhancement and relation to arterial, venous, and collecting system structures. To improve urographic phase MRI, concentrated Gadolinium in the collecting systems should be diluted. Diffusion-Weighted Imaging (DWI) should be performed before Gadolinium administration to minimize T2* effects. Renal sinus cysts are common but can occasionally be confused for dilated collecting system or calyceal diverticula, with the latter communicating with the collecting system and filling on urographic phase imaging. Vascular lesions (e.g., aneurysm, fistulas) may mimic cystic (or solid) lesions on non-enhanced MRI but can be suspected by noting similar signal intensity to the blood pool and diagnosis can be confirmed with MR angiogram/venogram. Multilocular cystic nephroma commonly extends to the renal sinus, however, to date are indistinguishable from cystic renal cell carcinoma (RCC). Solid hilar tumors are most commonly RCC and urothelial cell carcinoma (UCC). Hilar RCC are heterogeneous, hypervascular with epicenter in the renal cortex compared to UCC which are centered in the collecting system, homogeneously hypovascular, and show profound restricted diffusion. Diagnosis of renal sinus invasion in RCC is critically important as it is the most common imaging cause of pre-operative under-staging of disease. Fat is a normal component of the renal sinus; however, amount of sinus fat correlates with cardiovascular disease and is also seen in lipomatosis. Fat-containing hilar lesions include lipomas, angiomyolipomas, and less commonly other tumors which engulf sinus fat. Mesenchymal hilar tumors are rare. MR imaging diagnosis is generally not possible, although anatomic relations should be described to guide diagnosis by percutaneous biopsy or surgery.

R.E.N.A.L. Nephrometry Score: A Preoperative Risk Factor Predicting the Fuhrman Grade of Clear-Cell Renal Carcinoma

Objective: The purpose of this study was to evaluate the efficacy and feasibility of the R.E.N.A.L. Nephrometry Score to postoperatively predict high-grade clear-cell renal carcinoma (ccRCC). Methods: The study included 288 patients diagnosed with ccRCC who had complete CT/CTA data and R.E.N.A.L. Nephrometry Scores and underwent renal surgery at our center between January 2012 and December 2015. The relationship between the pathological grade of renal masses and R.E.N.A.L. Nephrometry Score was evaluated. Results: Univariate analysis indicated that diagnostic modality, cystic necrosis, enlargement of the regional lymph node, distant metastasis, clinical T stage, TNM stage, surgical modality, tumor size, nearness of the tumor to the collecting system or sinus, total Nephrometry Score and individual anatomic descriptor components were significantly associated with postoperative tumor grade (P < 0.05). Multivariate analysis showed that tumor size, the maximal diameter (R score), exophytic/endophytic properties (E score) and the location relative to the polar lines (L score) were independent prognostic factors to preoperatively predicting ccRCC pathological grade. The areas under the ROC curve with respect to the multi-parameter regression model (0.935, 95%CI: 0.904-0.966), tumor size (0.901, 95%CI: 0.866-0.937), R score (0.868, 95%CI: 0.825-0.911), E score (0.511, 95%CI: 0.442-0.581) and L score (0.842, 95%CI: 0.791-0.892) were calculated and compared. Conclusion: Tumor size, as well as R, E, and L scores were independent prognostic factors for high-grade pathology. Lager tumor sizes and higher R, E and L scores were more likely to be associated with high-grade pathological outcomes. Thus, the R.E.N.A.L. Score is of practical significance in facilitating urologists to make therapeutic decisions.

Renal Autotransplantation and Extracorporeal Nephron-Sparing Surgery for De Novo Renal Cell Carcinoma in a Kidney Allograft

De novo renal cell carcinoma (RCC) rarely occurs in kidney allografts; however, the risk of RCC in these patients is 100-fold that of the general healthy population. Although total nephrectomy has been the standard treatment for kidney allograft RCC, several authors have reported that early-stage RCC in kidney allografts was successfully treated with nephron-sparing surgery. We herein describe a new procedure involving renal autotransplantation and extracorporeal nephron-sparing surgery, which was performed to treat de novo RCC near the hilum of a transplanted kidney. In the 22 months since transplantation, the patient's renal function has been favorable, and no recurrence has been observed. In conclusion, renal autotransplantation is a feasible technique for the treatment of RCC in kidney allografts, especially RCC located near the hilum.

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.

Preserving Renal Function through Partial Nephrectomy Depends on Tumor Complexity in T1b Renal Tumors

This study aimed to determine patients with T1b renal cell carcinoma (RCC) who could benefit from partial nephrectomy (PN) and method to identify them preoperatively using nephrometry score (NS). From a total of 483 radical nephrectomy (RN)-treated patients and 40 PN-treated patients who received treatment for T1b RCC between 1995 and 2010, 120 patients identified through 1:2 propensity-score matching were included for analysis. Probability of chronic kidney disease (CKD) until postoperative 5-years was calculated and regressed with respect to the surgical method and NS. Median follow-up was 106 months. CKD-probability at 5-years was 40.7% and 13.5% after radical and PN, respectively (P = 0.005). While PN was associated with lower risk of CKD regardless of age, comorbidity, preoperative estimated renal function, the effect was observed only among patients with NS ≤ 8 (P < 0.001) but not in patients with NS ≥ 9 (P = 0.746). Percent operated-kidney volume reduction and ischemia time were similar between the patients with NS ≥ 9 and ≤ 8. In the stratified Cox regression accounting for the interaction observed between the surgical method and the NS, PN reduced CKD-risk only in patients with NS ≤ 8 (hazard ratio [HR], 0.054; P = 0.005) but not in ≥ 9 (HR, 0.996; P = 0.994). In T1b RCC with NS ≥ 9, the risk of postoperative CKD was not reduced following PN compared to RN. Considering the potential complications of PN, minimally invasive RN could be considered with priority in this subgroup of patients.

Retroperitoneoscopic Partial Nephrectomy for Moderately Complex Ventral Hilar Tumors: Surgical Technique and Trifecta Outcomes from a Single Institution in China

OBJECTIVES

T1 ventral renal hilar tumors (VRHTs) represent a very special type of tumor, for which laparoscopic partial nephrectomy (LPN) by the retroperitoneal approach is challenging. In this study, we report our surgical technique and Trifecta results.

METHODS

Renal rotation technique has been established for retroperitoneal laparoscopic partial nephrectomy (RLPN) for VRHTs in our institution. Trifecta was used as a composite outcome measure for assessing quality of PLPN using this technique. A retrospective analysis of RLPN cases in 12 patients with VRHTs was performed.

RESULTS

Mean tumor size was 3.4 cm and median R.E.N.A.L. score was 8 (range 7-9). Mean warm ischemia time was 23.1 minutes, suture time 28.1 minutes, estimated blood loss 139.2 mL, operation time 122.8 minutes, and median hospital stay was 4 days. Three patients (25.0%) had Clavien-Dindo grade I-II complications. Seven patients (58.3%) achieved Trifecta. Postoperative pathological examination showed renal cell carcinoma in all cases with negative surgical margin. A median follow-up of 7 months revealed no local recurrence or distant metastases.

CONCLUSIONS

Our Trifecta outcomes demonstrate that RLPN with renal rotation technique is feasible, safe, and effective for moderately complex VRHTs. The short-term functional and oncologic outcomes are promising; however, long-term follow-up is needed.

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.