Renal Function Outcomes and Risk Factors for Stage 3B Chronic Kidney Disease after Urinary Diversion in Patients with Muscle Invasive Bladder Cancer [corrected]

Effects of ileal conduit length on long-term kidney function decline after total pelvic exenteration for colorectal cancer

AIM

Understanding of kidney function decline (KFD) after pelvic exenteration (PE) for colorectal cancer remains limited, and the effects of a long ileal conduit (IC) on kidney disorders are unclear. The aim of this study was to investigate long-term kidney function following PE in colorectal cancer and to evaluate the effects of IC length on KFD.

METHOD

This was a retrospective, single-centre cohort study. KFD was defined as a decline in estimated glomerular filtration rate (eGFR) of ≥30% compared with preoperative data. IC length was measured from a postoperative computed tomography scan. The primary endpoint was the number of patients with KFD 5 years after surgery. The rate of decline of eGFR, cumulative KFD incidence and correlation between IC length and rate of decline of eGFR were also analysed. The patients were divided into two groups (short IC and long IC) based on an IC length of 20 cm.

RESULTS

Forty-three patients were included in the analysis. Fourteen (33%) and 29 (67%) patients were included in the short- and long-IC groups, respectively. The long-IC group was significantly more likely to be diagnosed with KFD within 5 years than the short-IC group (51% vs. 14%, p = 0.023). Multivariate analyses revealed that a longer IC was identified as an independent risk factor for KFD (hazard ratio 4.140, 95% CI 1.035-16.560, p = 0.045). Pearson's correlation and linear regression analyses demonstrated a significant association between IC length and rate of decline of eGFR (r = 0.466, p = 0.002).

CONCLUSION

A significant number of patients with colorectal cancer have decreased kidney function after PE. A longer conduit may impair kidney function.

Nomograms to Appraise The Risk of Chronic Kidney Disease After Radical Cystectomy: Shifting The Focus to Prevention

INTRODUCTION

Our objectives were to analyse the incidence of changes in renal function after radical cystectomy (RC) and determine the factors responsible for those changes, as a basis for rethinking strategies to ensure early detection and development of a risk-adapted approach.

PATIENTS AND METHODS

A single-centre retrospective study included 316 patients who underwent RC between 2010 and 2019. A competing risk Cox model, whereby death from any cause was treated as a censoring event, was used to establish nomograms to analyze the prognostic factors for CKD at 2 and 5 years. The nomograms were validated based on discrimination using the C-index, calibration plots and analysis of net benefit from decision curves.

RESULTS

During a median follow-up of 48.73 months (0.13-156.67), 138 patients (43.7%) developed CKD. The probability of CKD development at 2 and 5 years was 41.3% (95% CI, 35.8-47.2) and 48.5% (95% CI, 42.8-54.6), respectively. Hypertension (HR 1.69, 95% CI, 1.23-2.34), prior hydronephrosis (HR 1.62, 95% CI, 1.17-2.25), acute kidney injury (AKI) during the immediate postoperative period (HR 1.88, 95% CI, 1.35-2.61) and readmission due to urinary tract infection (HR 1.41, 95% CI, 1.01-1.96) were predictors of 2-year CKD. Hydronephrosis at follow-up computed tomography (HR 2.21, 95% CI, 1.60-3.07), prior hydronephrosis (HR 1.54, 95% CI, 1.09-2.15), AKI during the immediate postoperative period (HR 1.77, 95% CI, 1.27-2.46) and hypertension (HR 1.60, 95% CI, 1.16-2.21) were predictors for 5-year CKD. Prior eGFR ≥ 90 mL/min/1.73 m2 was a protective factor (HR 0.50, 95% CI, 0.32-0.80 and HR 0.48, 95% CI, 0.30-0.78 for 2- and 5-year CKD, respectively). The resulting nomograms were based on these prognostic factors.

CONCLUSION

Almost half of the patients had developed CKD at 5 years. Thus, it is crucial to identify patients at risk of developing CKD in order to initiate renal function-sparing measures and tailor follow-up protocols. The proposed nomograms effectively predicted CKD in these patients.

Colon Cancer With Bladder Invasion: A Single Center Experience

BACKGROUND/AIM

The aim of our study was to investigate the outcome of colon cancer with bladder invasion after surgical intervention.

PATIENTS AND METHODS

Between 2011 and 2022, a total of 41 patients diagnosed with colon cancer and bladder invasion underwent surgical procedures at Taichung Veterans General Hospital. The impact of various risk factors on overall survival (OS) was assessed using Kaplan-Meier analyses and Cox proportional hazards models.

RESULTS

Among the enrolled patients, 21 underwent radical cystectomy, while 20 underwent partial cystectomy. Twelve had tumors located in the rectum, 19 in the sigmoid colon, and 10 in both the rectum and sigmoid colon. The median OS was 71.8 months in stage 2, 50.8 months in stage 3, and 11.2 months in stage 4 (p=0.061). Median OS was 71.8 months in patients with negative surgical margins and 10.5 months in those with positive surgical margins (p=0.003). In multivariate regression analysis, positive surgical margins [hazard ratio (HR)=3.64, 95% confidence interval (CI)=1.28-10.34, p=0.015] and emergency operations (HR=4.57, 95%CI=1.34-15.55, p=0.015) significantly impacted OS.

CONCLUSION

Complete resection of colon cancer with bladder invasion can yield excellent oncologic outcomes. The decision between partial and radical cystectomy should balance surgical margin clearance and the preservation of quality of life. Both surgical margin involvement and emergency operations are independent risk factors for OS.

Survival of Patients with Chronic Kidney Disease Treated with Radical Cystectomy and Risk Factors of Glomerular Filtration Rate Loss Following Radical Cystectomy: Two Systematic Reviews and Meta-analyses of Interplay Between Radical Cystectomy and Renal Function

CONTEXT

There is no high-level evidence regarding the risk factors of glomerular filtration rate (GFR) loss following radical cystectomy (RC) and survival outcomes of patients with chronic kidney disease (CKD) undergoing RC.

OBJECTIVE

To identify the risk factors of CKD in patients treated with RC for bladder cancer and to assess overall and oncological survival of patients with CKD who underwent RC.

EVIDENCE ACQUISITION

According to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement, two systematic reviews were performed for studies published before September 30, 2022, assessing (1) risk factors of renal function (RF) decline following RC and (2) overall and oncological outcomes of CKD patients treated with RC.

EVIDENCE SYNTHESIS

A total of 21 and 17 studies were included for qualitative and quantitative syntheses, respectively. The first meta-analysis of ten studies (15 502 patients) identified these factors to be significantly associated with GFR loss following RC: advanced age, lower baseline RF, higher Charlson Comorbidity Index (CCI), diabetes mellitus, hypertension, postoperative hydronephrosis, ureteroenteric stricture, and locally advanced disease (hazard ratios [HRs] 1.03, 1.22, 1.5, 1.27, 1.24, 1.69, 1.92, and 5.13, respectively), while sex, preoperative hydronephrosis, perioperative chemotherapy, and diversion type were not. The second meta-analysis of seven studies (6900 patients) demonstrated significantly worse metastasis-free, cancer-specific, and overall survival in patients with higher CKD stages than in those with lower stages (HRs 1.54, 2.09, and 1.47, respectively).

CONCLUSIONS

Current evidence suggests that older age, lower baseline RF, higher CCI, diabetes mellitus, hypertension, postoperative hydronephrosis, ureteroenteric stricture, and locally advanced disease are associated with long-term GFR loss following RC. In addition, patients with higher stages of CKD have worse long-term overall and oncological outcomes following RC. These data may help in counseling and decision-making regarding therapy and preventive measures.

PATIENT SUMMARY

Several factors have been identified that can help identify patients at risk for glomerular filtration rate loss after radical cystectomy (RC). Chronic kidney disease is associated with poor cancer- and non-cancer-specific outcomes following RC.

Effect of decreased renal function on poor oncological outcome after radical cystectomy

PURPOSE

To evaluate the impact of preoperative renal impairment on the oncological outcomes of patients with urothelial carcinoma who underwent radical cystectomy.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients with urothelial carcinoma who underwent radical cystectomy from 2004 to 2017. All patients who underwent preoperative ^99mTc-diethylenetriaminepentaacetic acid renal scintigraphy (DTPA) were identified. We divided the patients into two groups according to their glomerular filtration rates (GFRs): GFR group 1, GFR≥90 mL/min/1.73 m²; GFR group 2, 60≤GFR<90 mL/min/1.73 m². We included 89 patients in GFR group 1 and 246 patients in GFR group 2 and compared the clinicopathological characteristics and oncological outcomes between the two groups.

RESULTS

The mean time required for recurrence was 125.5±8.0 months in GFR group 1 and 85.7±7.4 months in GFR group 2 (p=0.030). The mean cancer-specific survival was 131.7±7.8 months in GFR group 1 and 95.5±6.9 months in GFR group 2 (p=0.051). The mean overall survival was 123.3±8.1 months in GFR group 1 and 79.5±6.6 months in GFR group 2 (p=0.004).

CONCLUSIONS

Preoperative GFR values in the range of 60≤GFR<90 mL/min/1.73 m² are independent prognostic factors for poor recurrence-free survival, cancer-specific survival, and overall survival in patients after radical cystectomy compared with GFR values of ≥90 mL/min/1.73 m².

Long-term renal function in patients undergoing surgical reconstruction for tubercular cicatrized bladder

PURPOSE

We evaluated the long-term renal function in patients after surgical reconstruction for tuberculous contracted bladder (TBC) and determined factors associated with decreased renal function (RF) during follow up.

MATERIALS AND METHODS

We reviewed the records of 61 patients who underwent augmentation cystoplasty (AC) or orthotopic neobladder (ONB) for TBC between June 1994 and August 2019 in our institute. The estimated glomerular filtration rate (eGFR) was calculated preoperatively at initial presentation, before augmentation and at various intervals during follow up. Renal function decrease was defined as a defined as new-onset stage-3A Chronic kidney disease(CKD) or upstaging of pre-operative CKD stage 3A in follow-up. Multivariable analysis was done to evaluate the association of clinicopathological features and postoperative complications with decreased renal function.

RESULTS

We analyzed 39 patients who had a minimum follow-up of 1-year post reconstruction. At a median follow-up of 52 months (IQR 31-103 months), 16/39 patients developed RF decrease. In univariate analyses, initial eGFR, and associated ureteric stricture in contralateral renal unit were significantly associated with new-onset renal insufficiency (p < 0.001 each). On multivariable analysis, only initial presenting eGFR (p < 0.001) was an independent predictor of new-onset renal insufficiency. ROC cut-off levels for eGFR at presentation predicting the primary end point of RF decrease was 45 ml/min.

CONCLUSIONS

Decreased renal function is noted in most patients during long term follow-up after surgical reconstruction for TBC. After controlling for preoperative and postoperative risk factors, patients with initial presenting GFR < 45 ml/min are at greater risk of a decline in renal function following reconstruction.

Radical cystectomy and urinary diversion outcomes in patients with single vs. double renal unit: A 2:1 matched-pair analysis

OBJECTIVE

To evaluate perioperative and functional outcomes of radical cystectomy (RC) and urinary diversion (UD) in patients with a single kidney (SK) vs. double kidneys (DK).

METHODS

We reviewed records of patients who underwent RC for bladder cancer with a history of prior or concurrent nephrectomy at USC between 2004 and 2020. Patients with chronic kidney disease who were already on dialysis were excluded. UD, perioperative complications, and postoperative glomerular filtration rate (GFR) of the SK group were compared with a group of patients who underwent RC with DK using 2:1 matching with respect to age, sex, preop GFR, and tumor stage.

RESULTS

We included 186 patients (SK = 62 and DK = 124). Half of the SK patients underwent continent UD. SK patients had a higher length of hospital stay compared to the DK group; however, 90-day complications, readmission, and mortality rates were similar. In patients with continent diversion, SK vs. DK showed similar 90-day complications (71% vs. 69%, P = 1.0). SK patients had significantly lower GFRs at discharge, 3-, and 12-month following RC compared to the DK group. Postoperative GFRs of the SK patients with continent vs. incontinent UD were statistically similar. On multivariable analysis, UD (i.e. continent vs. incontinent) was not associated with post-op GFR decline at discharge, 3- and 12-month following RC.

CONCLUSIONS

Perioperative outcomes of radical cystectomy patients with single kidney are similar to double kidney patients, except for more GFR decline in single kidney cases. Continent urinary diversion in single kidney is as safe as double kidney patients.

Neobladder creation in patients with chronic kidney disease: A viable diversion strategy

INTRODUCTION

Renal function impairment is often cited as a contraindication to continent diversion strategies. There is little evidence exploring renal function changes between continent and incontinent surgery in patients with preoperative chronic kidney disease (CKD), in particular CKD3B.

METHODS

This was a retrospective review of two high-volume centers performing robotic assisted radical cystectomy (RARC) with orthotopic neobladder (ONB) or ileal conduit (IC) between 2014 to 2020. Patients were stratified based on CKD estimated glomerular filtration (eGFR) stage, which was estimated via the CKD-EPI equation. Postoperative renal function was compared for up to 60 months postoperative. Surgical, post-surgical, complications, and readmission data were gathered and compared between all patients RESULTS: 522 cystectomy patients, 430 with IC and 125 with ONB, were included. eGFR decline was statistically significant in a matched cohort of IC and ONB patients only at 3 months. There were no statistically significant differences between readmission rates, time to readmission, or complications. 34.6% of stage 3B patients had hydronephrosis on imaging prior to surgery, compared to 11.4%, 22.1% and 21.8% of CKD stage 1, 2, and 3A patients. CKD stage 3B had statistically and clinically improved eGFR through 24 months.

CONCLUSION

ONB surgery may be a viable diversion strategy in patients previously thought to be contraindicated due to low renal function.

Ileal conduit versus neobladder: A propensity score-matched analysis of the effect on renal function

OBJECTIVES

To analyze the long-term effects of continent (neobladder) compared with incontinent (ileal conduit) urinary diversion.

METHODS

We carried out a retrospective review of our departmental database. Estimated glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Neobladder and ileal conduit patients were matched in a 1:2 ratio and a propensity score-matched analysis was carried out. Data were summarized using descriptive analysis. Trend plots were generated using baseline and follow-up creatinine values to compare estimated glomerular filtration rate at 3 months, then annually for 5 years. Variables associated with estimated glomerular filtration rate were assessed using multivariate linear analysis.

RESULTS

Our cohort consisted of 137 patients (neobladder n = 50 and ileal conduit n = 87) with a median follow-up time of 3 years (interquartile range 1-7 years). The ileal conduit group had shorter operative times (352 vs 444 min, P < 0.01), intracorporeal diversions were more common (66% vs 44%, P = 0.01), had prior abdominal surgery (66% vs 38%, P < 0.01) and had radiation (9% vs 0%, P = 0.03). The neobladder group more commonly had recurrent urinary tract infections (22% vs 3%, P < 0.01) and a steeper decrease in estimated glomerular filtration rate in the first year. On multivariate linear analysis, age/year (-0.59), body mass index per kg/m2 (-0.52), preoperative estimated glomerular filtration rate per unit (0.51), recurrent urinary tract infections (-14.03) and time versus day 90 (year 1, -7.52; year 2, -9.06; year 3, -10.78) were significantly associated with estimated glomerular filtration rate.

CONCLUSION

Ileal conduits and neobladders showed a similar effect on the estimated glomerular filtration rate up to 5 years after robot-assisted radical cystectomy. Recurrent urinary tract infections were associated with a worse estimated glomerular filtration rate.

The MicroRNA Prediction Models as Ancillary Diagnosis Biomarkers for Urothelial Carcinoma in Patients With Chronic Kidney Disease

Urothelial carcinoma is a common urological cancer in chronic kidney disease patients. Cystoscopy and urine cytology are the clinical diagnostic tools for UC. However, cystoscopy is an invasive procedure, while urine cytology showed low sensitivity for low-grade urothelial tumors. High accuracy with non-invasive tools for UC is needed for CKD patients. Our study collected a total of 272 urine and 138 plasma samples to detect the miRNA expression levels for establishing UC signatures from CKD patients. Seventeen candidate miRNAs of biofluids were selected and confirmed by qRT-PCR. Our results showed that urinary miR-1274a and miR-30a-5p expression levels were significantly lower but miR-19a-5p expression levels were higher in UC when compared with CKD. In plasma samples, miR-155-5p, miR-19b-1-5p, miR-378, and miR-636 showed significantly lower expression in UC compared to those with CKD. The Kaplan-Meier curve showed that lower expression of miR-19a, miR-19b, miR-636 and miR-378, and higher expression of miR-708-5p were associated with poor prognosis in patients with bladder cancer. In addition, we produced classifiers for predicting UC by multiple logistic regression. The urine signature was developed with four miRNAs, and the AUC was 0.8211. Eight miRNA expression levels from both urine and plasma samples were examined, and the AUC was 0.8595. Two miRNA classifiers and the nomograms could improve the drawbacks of current UC biomarker screenings for patients with CKD.

Significance of urinary liver-type fatty acid-binding protein in patients with normal renal function after undergoing intestinal urinary diversion: a preliminary study

BACKGROUND

Liver-type fatty acid-binding protein (L-FABP) in urine is one of the early diagnostic biomarkers for acute and chronic kidney injuries. Although this protein is also identified in the intestine, there is no verified reference value for patients with intestinal urinary diversion (UD). The aim of the present study was to measure L-FABP values in such patients and compare them with the results for patients without UD.

METHODS

Spot urine specimens were collected from 41 patients with UD and 50 subjects without UD with estimated glomerular filtration rates of over 60 ml/min/1.73 m², and the L-FABP values were measured. The normal upper cutoff value in healthy subjects without UD is considered to be 7.24 μg/g Cr. First, the median values of the two groups were compared. Next, the subjects with negative proteinuria and without comorbidities associated with renal function were further selected and the median values of the groups were compared.

RESULTS

The mean age was significantly higher in the UD group. The types of UD were ileal conduit (38 patients) and ileal neobladder (three patients). The median L-FABP value in the UD group was significantly higher than that in the non-diversion group (89.1 μg/g Cr vs. 2.0 μg/g Cr, p < 0.0001). After adjustment for their backgrounds, the median value remained higher in the UD group.

CONCLUSIONS

L-FABP values in subjects with UD are higher than in those without UD. By this result, to develop a reference value in patients with intestinal UD population, further studies are required.

Renal function outcomes in the early and intermediate phases after radical cystectomy by ileal conduit

Introduction and Objectives: An ileal conduit (IC) is an established option for urinary diversion, despite the fact that early renal impairment (RI) sometimes occurs after surgery. The aim of this study was to investigate the incidence and risk factors of early RI.

Materials and Methods: Thirty-one patients diagnosed with muscle-invasive bladder cancer who underwent RC with IC were analyzed in this study. Early RI was defined as a greater than 25% decrease in estimated glomerular filtration rate (eGFR) over the course of one year after surgery. The incidence and risk factors of early RI were evaluated.

Results: The mean preoperative eGFR of the patients was 69.6 mL/min/1.73 m². Early RI was observed in 7 (22.5%) patients. Multivariate analyses demonstrated that postoperative hydronephrosis was an independent risk factor for early RI (P=0.018). The mean intermediate-term eGFR change was −5.1 mL/min/1.73 m² in patients with early RI and was greater than that (−2.9) in patients without early RI, although neither were statistically significantly different.

Conclusion: Renal function after RC with IC decreased immediately over the course of one year, and postoperative hydronephrosis was an independent risk factor for early RI. Renal function had decreased slightly at intermediate-term follow-up with or without early RI.

Measured glomerular filtration rate (GFR) significantly and rapidly decreases after radical cystectomy for bladder cancer

Precise determination of glomerular filtration rate (GFR) is essential for the management of patients with muscle-invasive bladder cancer (MIBC). We aim to describe the early evolution of measured GFR (mGFR) after radical cystectomy and urinary diversion (RCUD) and to identify risk factors for GFR decline. GFR measurement using ⁵¹Cr-EDTA continuous infusion, estimated GFR (eGFR) from five published equations and renal scintigraphy with split renal function determination were performed before and 6 months after RCUD. Chronic Kidney Disease (mGFR < 60 mL/min/1.73 m²) and GFR stages were defined according to the KDIGO guidelines using mGFR. Twenty-seven patients (men 85%, median age 65, IQR 59; 68 years) were included. A total of 20 (74%) patients experienced significant mGFR decline at 6 months postoperatively. Median mGFR decreased from 84.1 pre-operatively (IQR 65.3; 97.2) to 69.9 mL/min/1.73 m² (IQR 55.0; 77.9) 6 months after surgery (p < 0.001). Thirteen (48%) patients had a progression to a worse GFR stage. Of the 22 patients without pre-operative CKD, 5 (23%) developed post-operative CKD. Diabetes mellitus was more frequent in patients in the highest tertile of relative mGFR decline (44% vs. 11%, p = 0.02) and platinum-based adjuvant chemotherapy tended to be more frequently used in these patients (44% vs. 17%, p = 0.06). Importantly, pre-operative weight was independently and negatively associated with post-operative mGFR and with mGFR slope in multivariable analyses. In this prospective series, we demonstrated that early and significant mGFR decline occurred after RCUD and perioperative platinum-based chemotherapy, especially in patients with diabetes mellitus and overweight.

Impact of chronic kidney disease on oncological outcomes in patients with high-risk non-muscle-invasive bladder cancer who underwent adjuvant bacillus Calmette-Guérin therapy

OBJECTIVES

To investigate the impact of chronic kidney disease (CKD) on oncological outcomes in patients with high-risk non-muscle invasive bladder cancer (NMIBC) who underwent adjuvant induction bacillus Calmette-Guérin (BCG) therapy after transurethral resection of bladder tumor (TURBT).

MATERIALS AND METHODS

We conducted a multi-institutional retrospective study assessing 209 patients with high-risk NMIBC who underwent TURBT and subsequent adjuvant induction BCG therapy from December 1998 to April 2019. Patients were divided into 2 groups: those with preoperative estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m² (non-CKD group), and those with eGFR < 60 ml/min/1.73 m² (CKD group). Primary endpoints were intravesical recurrence-free survival (RFS) and muscle-invasive bladder cancer (MIBC)-free survival. Background-adjusted multivariate analyses with the inverse probability of treatment weighting (IPTW) method using the propensity score were performed to evaluate the impact of CKD on intravesical RFS, MIBC-free survival, metastasis-free survival, cancer-specific survival, and overall survival. Moreover, multivariable analyses were performed to assess the impact of CKD on intravesical recurrence and MIBC progression, adjusting for the competing risk of death using the Fine-Gray competing risk regression model.

RESULTS

Median age and follow-up period after TURBT were 72 years and 45 months, respectively. Of 209 patients, 71 (34%) were diagnosed with CKD before TURBT. Background-adjusted multivariate analyses with the IPTW method indicated that CKD was significantly associated with shorter intravesical RFS, MIBC-free survival, metastasis-free survival, cancer-specific survival, and overall survival. In the Fine-Gray competing risk regression model, CKD showed significantly higher probabilities of intravesical recurrence and MIBC progression, with an adjusted subdistribution hazard ratio of 1.886 (95% confidence interval 1.069-3.330, P = 0.028) and 3.740 (95% confidence interval 1.060-13.20, P = 0.040), respectively.

CONCLUSIONS

CKD presents a risk factor of poor oncological outcomes in patients with high-risk NMIBC who underwent adjuvant induction BCG therapy after TURBT.

Short- and Long-Term Evaluation of Renal Function after Radical Cystectomy and Cutaneous Ureterostomy in High-Risk Patients

Deterioration of renal function has been reported after radical cystectomy (RC) with urinary diversion. We investigated renal function changes in elderly bladder cancer (BCa) patients who underwent RC with cutaneous ureterostomy (CU) urinary diversion. We performed a retrospective, observational study. BCa patients aged ≥75 with an American Society of Anesthesiologists (ASA) class greater than II were included. Glomerular filtration rate (GFR) was the main outcome measure. GFR values were recorded preoperatively, at discharge, at 6-month follow-up, and yearly up to 60 months. A total of 70 patients with a median age of 78.0 years were identified. Median preoperative GFR was 74.3 mL/min/1.73 m2 and declined significantly to 54.6 mL/min/1.73 m2 after 6 months (p < 0.001). A gradual GFR decline was observed thereafter, reaching a median value of 46.2 after 60 months. Preoperative GFR and acute kidney injury were significant predictors of fast deterioration of GFR and of 25% deterioration of GFR after 12 months. Elderly BCa patients with high comorbidity rates undergoing RC with CU should be carefully informed about the risk of GFR deterioration and the need for adequate monitoring.

Development and Cross-Validation of a Nomogram for Chronic Kidney Disease Following Robot-Assisted Radical Cystectomy

Introduction: We sought to identify the factors associated with deterioration of renal functions after robot-assisted radical cystectomy, and to develop a nomogram to detect the probability of progression to chronic kidney disease (CKD). Materials and Methods: A retrospective review of our prospectively maintained database. Estimated glomerular filtration rate (eGFR) was calculated using the CKD-Epidemiology Collaboration creatinine formula utilizing all follow-up creatinine values. CKD was defined as stage 3b (eGFR <45 mL/minute/1.73 m²) based on the National Kidney Foundation classification. Kaplan-Meier curves were used to depict CKD-free survival. A multivariate Cox regression model was used to determine predictors for CKD and to build the perioperative nomogram. Results: The data set comprised 442 patients with a median follow-up of 25 months (12-59). Thirty-seven percent developed CKD at a median of 9 months (4-18). CKD-free survival rates at 1, 3, and 5 years were 75%, 58%, and 50%, respectively. CKD was significantly associated with preoperative eGFR (hazards ratio [HR]: 0.96, 95% confidence interval [CI]: 0.95-0.97, p < 0.01), body mass index (HR: 1.03, 95% CI: 1.01-1.05, p = 0.03), Charlson Comorbidity Index ≥3 (HR: 2.20, 95% CI: 1.35-3.58, p < 0.01), diabetes (HR: 1.59, 95% CI: 1.09-2.31, p = 0.02), 90 days postoperative strictures (HR: 4.04, 95% CI: 1.76-9.30, p < 0.01), 90 days postoperative hydronephrosis (HR: 2.26, 95% CI: 1.34-3.79, p < 0.01), 90 days recurrent urinary tract infection (HR: 1.84, 95% CI: 1.08-3.14, p = 0.02), 90 days acute kidney injury (HR: 1.70, 95% CI: 1.19-2.43, p < 0.01), and node positive disease (HR: 1.94, 95% CI: 1.31-2.86, p < 0.01). A 5-year CKD-free survival nomogram was developed. Conclusion: We have developed and cross-validated a nomogram for detecting CKD-free survival. This nomogram may have a role in counseling and follow up of patients. This study was done after the approval of the IRB committee (I-79606).

Frailty is significantly associated with the type of urinary diversion in patients with muscle-invasive bladder cancer

OBJECTIVES

To investigate the effect of frailty on the type of urinary diversion after radical cystectomy in patients with muscle-invasive bladder cancer.

METHODS

Between January 2014 and January 2020, we prospectively evaluated frailty in 88 patients with localized muscle-invasive bladder cancer, who had received radical cystectomy and urinary diversion. The selection of the type of urinary diversion was determined by the operating surgeon based on performance status, comorbidities, tumor status and the patient's preference. The frailty evaluation included the Fried phenotype criteria, the modified frailty index and the frailty discriminant score. We investigated the association between frailty and type of urinary diversion, the effect of frailty on postoperative complications and the effect of frailty on overall survival.

RESULTS

The median age of the selected participants was 68 years. The number of patients with an orthotopic neobladder and any postoperative complications was 54 (61%) and 46 (52%), respectively. Of the frailty assessment tools that were used, Fried phenotype criteria and frailty discriminant score were significantly associated with the selection of non-orthotopic neobladder urinary diversion. Occurrences of postoperative complications in participants were significantly associated with modified frailty index, but not with Fried phenotype criteria and frailty discriminant score. Multivariate Cox regression analysis showed that a higher frailty discriminant score was significantly associated with poor overall survival, whereas higher Fried phenotype criteria and modified frailty index were not.

CONCLUSION

Frailty is significantly associated with the type of urinary diversion, and it should be considered for the selection of urinary diversion in muscle-invasive bladder cancer patients undergoing radical cystectomy.

Preoperative chronic kidney disease predicts poor prognosis in patients with primary non-muscle-invasive bladder cancer who underwent transurethral resection of bladder tumor

OBJECTIVES

To evaluate the impact of preoperative chronic kidney disease (CKD) on the prognosis of patients with primary non-muscle-invasive bladder cancer (NMIBC) who underwent transurethral resection of bladder tumor (TURBT).

MATERIALS AND METHODS

We retrospectively evaluated 434 patients with primary NMIBC who underwent TURBT from November 1993 to April 2019. The patients were divided into 2 groups: patients with preoperative estimated glomerular filtration rate ≥60 ml/min/1.73 m² (non-CKD group) and <60 ml/min/1.73 m² (CKD group). Background-adjusted multivariate analyses were performed to evaluate the effect of preoperative CKD on oncological outcomes, including intravesical recurrence-free survival, muscle-invasive bladder cancer-free survival, upper urinary tract (UUT) recurrence-free survival, metastasis-free survival, cancer-specific survival, and overall survival. We evaluated predictive accuracy of CKD on prognosis using the receiver operating characteristic curve and compared between risk factors in the European Organization for Research and Treatment of Cancer scoring system and CKD plus those risk factors.

RESULTS

The median age and median follow-up period were 72 years and 51 months, respectively. Of 434 patients, 141 (32%) were diagnosed with CKD before TURBT. In background-adjusted multivariate analyses, CKD was an independent risk factor for those oncological outcomes, except for UUT recurrence. The predictive accuracy of CKD plus risk factors in the European Organization for Research and Treatment of Cancer scoring system on oncological outcomes was significantly improved compared with those risk factors alone, except for UUT recurrence.

CONCLUSION

Preoperative CKD was a risk factor and might improve predictive accuracy on poor prognosis in patients with primary NMIBC who underwent TURBT.

Acute kidney injury following radical cystectomy and urinary diversion: predictors and associated morbidity

Introduction:

Acute kidney injury (AKI) after major surgeries is associated with significant morbidity and mortality. We aim to report incidence, predictors and associated comorbidities of AKI after radical cystectomy in a large cohort of patients.

Materials and Methods:

We conducted a retrospective analysis of 1000 patients who underwent open radical cystectomy in a tertiary referral center. Perioperative serum creatinine measurements were used to define AKI according to the RIFLE criteria (as Risk, Injury and Failure). The predictors of AKI after surgery were determined using univariate and multivariate analyses.

Results:

Out of 988 evaluable patients, AKI developed in 46 (4.7%). According to RIFLE criteria; AKI-Risk, AKI-Injury and AKI-Failure occurred in 26 (2.6%), 9 (0.9%) and 11 (1.1%) patients, respectively. Multivariate analysis showed that performing nephroureterectomy with cystectomy (Odds ratio [OR]: 4.3; 95% Confidence interval [CI]: 1.3-13.6; p=0.01) and the development of high grade complications (OR: 3.8; 95% CI 1.9-7.2; p<0.0001) were independently associated with AKI.

Conclusions:

AKI is a significant morbidity after radical cystectomy and the term should be included during routine cystectomy morbidity assessment.

Clinical implication of a quantitative frailty assessment tool for prognosis in patients with urological cancers

Objectives

Optimal tools for evaluating frailty among urological cancer patients remain unclear. We aimed to develop a quantitative frailty assessment tool comparing healthy individuals and urological cancer patients, and investigate the clinical implication of quantitative frailty on prognosis in urological cancer patients.

Results

Gait speed, hemoglobin, serum albumin, exhaustion, and depression were significantly worse in patients with all types of cancers than in pair-matched controls. Frailty discriminant score (FDS) showed clear separation between controls and urological cancer patients, and significant association with the Fried criteria. Overall survivals were significantly shorter in patients with a higher score (>2.30) than in those with a lower score among nonprostate cancer (bladder, upper tract urothelial carcinoma, and renal cell carcinoma) patients. In prostate cancer patients, overall survivals were significantly shorter in patients with a higher score (>3.30) than in those with a lower score.

Conclusions

FDS was significantly associated with frailty and prognosis in urological cancer patients. This tool for frailty assessment can help patients and physicians make more informed decisions. Further validation study is needed.

Materials and Methods

Total 605 urological cancer patients presenting to our hospital underwent a prospective frailty assessment. Controls were selected from 2280 community-dwelling subjects. Frailty was assessed via physical status, blood biochemical tests, and mental status. We compared frailty variables between pair-matched controls and urological cancer patients. We developed FDS using frailty variables, and compared with the Fried criteria. The influence of FDS on overall survivals was investigated by Kaplan-Meier analysis and Cox regression analysis.

Presence of transient hydronephrosis immediately after surgery has a limited influence on renal function 1 year after ileal neobladder construction

Background

Urinary tract obstruction and postoperative hydronephrosis are risk factor for renal function deterioration after orthotopic ileal neobladder construction. However, reports of relationship between transient hydronephrosis and renal function are limited.

We assess the influence of postoperative transient hydronephrosis on renal function in patients with orthotopic ileal neobladder construction.

Methods

Between January 2006 and June 2013, we performed radical cystectomy in 164 patients, and 101 received orthotopic ileal neobladder construction. This study included data available from 64 patients with 128 renal units who were enrolled retrospectively. The hydronephrosis grade of each renal unit scored 0–4. The patients were divided into 4 groups according to the grade of hydronephrosis: control, low, intermediate, and high. The grade of postoperative hydronephrosis was compared with renal function 1 month and 1 year after surgery.

Results

There were no significant differences in renal function before surgery between groups. One month after surgery, the presence of hydronephrosis was significantly associated with decreased renal function. However, 1 year after urinary diversion hydronephrosis grades were improved significantly, and renal function was comparable between groups. Postoperative hydronephrosis at 1 month had no significant influence on renal function 1 year after ileal neobladder construction. Limitations include retrospective design, short follow-up periods, and a sample composition.

Conclusions

The presence of transient hydronephrosis immediately after surgery may have limited influence on renal function 1 year after ileal neobladder construction.

The influence of serum uric acid on renal function in patients with calcium or uric acid stone: A population-based analysis

OBJECTIVES

To determine the influence of serum uric acid (UA) levels on renal impairment in patients with UA stone.

MATERIALS AND METHODS

We retrospectively analyzed 463 patients with calcium oxalate and/or calcium phosphate stones (CaOx/CaP), and 139 patients with UA stones. The subjects were divided into the serum UA-high (UA ≥ 7.0 mg/dL) or the UA-low group (UA < 7.0 mg/dL). The control group comprised 3082 community-dwelling individuals that were pair-matched according to age, sex, body mass index, comorbidities, hemoglobin, serum albumin, and serum UA using propensity score matching. We compared renal function between controls and patients with UA stone (analysis 1), and between patients with CaOx/CaP and with UA stone (analysis 2). Logistic regression analysis was used to evaluate the impact of the hyperuricemia on the development of stage 3 and 3B chronic kidney disease (CKD) (analysis 3).

RESULTS

The renal function was significantly associated with serum UA levels in the controls and patients with CaOx/CaP and UA stones. In pair-matched subgroups, patients with UA stone had significantly lower renal function than the control subjects (analysis 1) and patients with CaOx/CaP stones (analysis 2) regardless of hyperuricemia. Multivariate logistic regression analysis revealed that patients with UA stone, CaOx/CaP, hyperuricemia, presence of cardiovascular disease, higher body mass index, older age and lower hemoglobin had significantly higher risk of stage 3 and 3B CKD (analysis 3).

CONCLUSION

Patients with UA stones had significantly worse renal function than controls and CaOx/CaP patients regardless of hyperuricemia. Urolithiasis (CaOx/CaP and UA stone) and hyperuricemia had an association with impaired renal function. Our findings encourage clinicians to initiate intensive treatment and education approaches in patients with urolithiasis and/or hyperuricemia in order to prevent the progression of renal impairment.

Preoperative chronic kidney disease predicts poor oncological outcomes after radical cystectomy in patients with muscle-invasive bladder cancer

OBJECTIVE

To evaluate the impact of preoperative chronic kidney disease (CKD) on oncologic outcomes in muscle-invasive bladder cancer patients who underwent radical cystectomy.

METHODS

A total of 581 patients who underwent radical cystectomy at four medical centers between January 1995 and February 2017 were examined retrospectively. We investigated oncologic outcomes, including progression-free, cancer-specific, and overall survival (PFS, CSS, and OS, respectively) stratified by preoperative CKD status (pre-CKD vs. non-CKD). We performed a Cox proportional hazards regression analysis using inverse probability of treatment weighting (IPTW) to evaluate the impact of preoperative CKD on prognosis and developed the prognostic factor-based risk stratification nomogram.

RESULTS

Of the 581 patients, 215 (37%) were diagnosed with CKD before radical cystectomy. Before the background adjustment, PFS, CSS, and OS after radical cystectomy were significantly lower in the pre-CKD group compared to the non-CKD group. Background-adjusted IPTW analysis showed that preoperative CKD was significantly associated with poor PFS, CSS, and OS after radical cystectomy. The nomogram for predicting 5-year PFS and OS probability showed significant correlation with actual PFS and OS (c-index = 0.73 and 0.77, respectively).

CONCLUSIONS

Muscle-invasive bladder cancer patients with preoperative CKD had a significantly lower survival probability than those without CKD.

Clinical relevance of aortic calcification in urolithiasis patients

Background

The aim of the present study is to investigate the clinical relevance of aortic calcification in urolithiasis patients.

Methods

Between January 2010 and September 2014, 1221 patients with urolithiasis were treated in Oyokyo Kidney Research Institute and Hirosaki University Hospital. Among these, 287 patients (Stone group) on whom adequate data were available were included in this retrospective study. We also selected 148 subjects with early stage (pT1N0M0) renal cell carcinoma from 607 renal cell carcinoma patients who underwent radical nephrectomy at Hirosaki University Hospital (Non-stone group) as control subjects. Validity of the Non-stone group was evaluated by comparison with pair-matched 296 volunteers from 1166 subjects who participated in the Iwaki Health Promotion Project in 2014. Thereafter, age, body mass index, aortic calcification index (ACI), renal function, serum uric acid concentrations, and comorbidities (diabetes, hypertension, or cardiovascular disease) were compared between the Non-stone and Stone groups. Independent factors for higher ACI and impaired renal function were assessed using multivariate logistic regression analysis.

Results

We confirmed relevance of Non-stone group patients as a control subject by comparing the pair-matched community-dwelling volunteers. Backgrounds of patients between the Non-stone and Stone groups were not significantly different except for the presence of hypertension in the Stone group. ACI was not significantly high in the Stone group compared with the Non-stone group. However, age-adjusted ACI was greater in the Stone group than the Non-stone group. Among urolithiasis patients, ACI was significantly higher in uric acid containing stone patients. The number of patients with stage 3B chronic kidney disease (CKD) was significantly higher in the Stone group than in the Non-stone group (12% vs. 4%, P = 0.008). Multivariate logistic regression analysis showed higher aortic calcification index (>13%), and being a stone former were independent factors for stage 3B CKD at the time of diagnosis.

Conclusion

Aortic calcification and being a stone former had harmful influence on renal function. This study was registered as a clinical trial: UMIN: UMIN000022962.