Partial versus Radical Nephrectomy for T1-T2 Renal Cell Carcinoma in Patients with Chronic Kidney Disease Stage III: a Multiinstitutional Analysis of Kidney Function and Survival Rate

Renal and major clinical outcomes and their determinants after nephrectomy in patients with pre-existing chronic kidney disease: A retrospective cohort study

The consequences of partial nephrectomy (PN) compared to radical nephrectomy (RN) are less documented in patients with pre-existing chronic kidney disease (CKD) or with solitary kidney (SK). We assessed renal outcomes, and their determinants, after PN or RN in a retrospective cohort of patients with moderate-to-severe CKD (RN-CKD and PN-CKD) or SK (PN-SK). All surgical procedures conducted between 2013 and 2018 in our institution in patients with pre-operative estimated glomerular filtration rate (eGFR)<60 mL/min/1.73m2 or with SK were included. The primary outcome was a composite criterion including CKD progression or major adverse cardio-vascular events (MACE) or death, assessed one year after surgery. Predictors of the primary outcome were determined using multivariate analyses. A total of 173 procedures were included (67 RN, and 106 PN including 27 SK patients). Patients undergoing RN were older, with larger tumors. Preoperative eGFR was not significantly different between the groups. One year after surgery, PN-CKD was associated with lower rate of the primary outcome compared to RN-CKD (43% vs 71% p = 0.007). In multivariate analysis, independent risk factors for the primary outcome were postoperative AKI (stage 1 to stage 3 ranging from OR = 8.68, 95% CI 3.23-23.33, to OR = 28.87, 95% CI 4.77-167.61), larger tumor size (OR = 1.21 per cm, 95% CI 1.02-1.45), while preoperative eGFR, age, sex, diabetes mellitus, and hypertension were not. Postoperative AKI after PN or RN was the major independent determinant of worse outcomes (CKD progression, MACE, or death) one year after surgery.

Renal functional and cardiovascular outcomes of partial nephrectomy versus radical nephrectomy for renal tumors: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to evaluate the postoperative renal and cardiovascular outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) for the treatment of renal carcinoma. A systematic literature search was performed on scientific databases including Scopus, Web of Science, MEDLINE, and EMBASE from their inception to September 2021. Studies comparing renal and cardiovascular outcomes between PN and RN in patients with renal cancer were included. The generic inverse variance method with random-effects models was used to determine the pooled hazard ratios and odds ratio for each outcome. Quality Assessment for observational studies was guided by the New-Castle Ottawa Scale. Overall, a total of 31 studies (n=51,866) reported renal outcomes, while 11 studies (n= 101,678) reported cardiovascular outcomes. When compared to PN, RN had a higher rate of new-onset postoperative EGFR <60 mL/min/1.73 m² (HR 3.39; CI 2.45 - 4.70; I²=93%; P=<0.00001) and EGFR <45 mL/min/1.73 m² (HR 4.70; CI 2.26 - 9.79; I²=98%; P=<0.0001). No difference was observed in new-onset advanced kidney disease and end-stage renal disease. A 19% reduction in cardiovascular events was observed in the PN group (HR 0.81; CI 0.70 - 0.93, P=0.002). No protective effect of PN was observed in new-onset or worsening hypertension (HR 0.85; CI 0.64 - 1.14, P=0.28) nor myocardial infarction (HR 0.86; CI 0.71 - 1.04, P=0.13). PN was associated with a decreased risk of postoperative early-stage CKD and cardiovascular events compared with RN. However, no benefit of PN over RN was observed in advanced CKD, new-onset or worsening hypertension, myocardial infarction, and cardiovascular mortality.

The Role of Intraoperative Ultrasonography Associated with Clampless Technique in Three-Dimensional Retroperitoneoscopic Laparoscopic Enucleation of Completely Endophytic Renal Tumors

Objectives: To evaluate perioperative and functional outcomes of clampless laparoscopic tumor enucleation for completely endophytic renal tumors with the guide of intraoperative ultrasonography. Methods: We analyzed patients with clinically completely endophytic tumors, renal tumors, who underwent clampless three-dimensional (3D) retroperitoneoscopic laparoscopic tumor enucleation between January 2012 and January 2021. Patients with exophytic tumors were excluded. Intraoperative ultrasonography was used to map out the mass in all surgeries. Results: Overall, 57 patients underwent clampless 3D retroperitoneoscopic laparoscopic tumor enucleation. Mean surgical time was 131 minutes, and mean estimated blood loss was 202 mL. Mean hospital stay was 4.7 days. Major and minor postoperative complications occurred, respectively, in 3 and 10 cases. Only a patient had a positive surgical margin. One-year renal function did not differ from baseline. Conclusion: Our study showed that clampless laparoscopic enucleation guided by laparoscopic ultrasonography ensured satisfactory outcomes for completely intrarenal tumors, with excellent renal function preservation 1 year after surgery.

Partial versus radical nephrectomy in clinical T2 renal masses

OBJECTIVE

To report perioperative, renal functional and oncologic outcomes for patients undergoing partial or radical nephrectomy for cT2 renal masses.

METHODS

Retrospective review of patients who underwent partial (n = 72) or radical nephrectomy (n = 379) for cT2 renal masses from 2000 to 2016. After propensity adjustment using inverse probability weighting, the following were compared by surgery (partial or radical nephrectomy): complications, renal function measured by estimated glomerular filtration rate as continuous and as <60 mL/min/1.73 m² at 1 and 3 years postoperatively and overall, metastases-free survival and cancer-specific survival in patients with renal cell carcinoma.

RESULTS

After propensity adjustment, clinical and radiographic features were well-balanced between groups. Overall and severe complications were more common for partial compared with radical nephrectomy, although not statistically significant (19 vs 13%, P = 0.14 and 4 vs 2%, P = 0.3, respectively). Estimated glomerular filtration rate change at 1 and 3 years was more pronounced in radical compared with partial nephrectomy (median -16 vs -5 and -14 vs -2, respectively, P < 0.001). A greater proportion of radical nephrectomy patients had an estimated glomerular filtration rate <60 at 1 and 3 years (55 vs 17% and 48 vs 17%, respectively, P < 0.01). In renal cell carcinoma patients, overall, metastases-free and cancer-specific survival were not significantly different between groups (median survivor follow up 7.1 years, interquartile range 3.6-11.4).

CONCLUSIONS

Partial nephrectomy appears to be a relatively safe and a potentially effective treatment for cT2 renal masses, conferring better renal functional preservation compared with radical nephrectomy. These data support continued use of partial nephrectomy for renal masses >7 cm in appropriately selected patients.

Partial Nephrectomy Versus Radical Nephrectomy for Clinical T2 or Higher Stage Renal Tumors: A Systematic Review and Meta-Analysis

OBJECTIVE

The choice of surgical method for clinically diagnosed T2 or higher stage kidney cancer remains controversial. Here, we systematically reviewed and collected published comparative studies on renal function, oncologic outcomes, and perioperative results of partial nephrectomy (PN) versus radical nephrectomy (RN) for larger renal tumors (T2 and above), and performed a meta-analysis.

EVIDENCE ACQUISITION

Following searches of PubMed, Web of Science, and Embase, the original studies on PN vs. RN in the treatment of T2 renal cancer were screened through strict inclusion and exclusion criteria. RevMan 5.4 was used for data analysis of the perioperative results, renal function, and oncologic outcomes of the two surgical methods for T2 renal tumor therapy. The weighted mean difference was used as the combined effect size for continuous variables, while the odds ratio (OR) or risk ratio (RR) was used as the combined effect size for binary variables. Both variables used a 95% confidence interval (CI) to estimate statistical accuracy. In cases with low heterogeneity, the fixed-effects model was used to pool the estimated value; otherwise, the random-effects model was used when significant heterogeneity was detected.

RESULTS

Fifteen retrospective studies including 5,056 patients who underwent nephrectomy (PN: 1975, RN: 3081) were included. The decline in estimated GFR (eGFR) after PN was lower than RN [(MD: -11.74 ml/min/1.73 m2; 95% CI: -13.15, -10.32; p < 0.00001)]. The postoperative complication rate of PN was higher than that of PN (OR: 2.09; 95% CI: 1.56, 2.80; p < 0.00001)], and the postoperative overall survival (OS) of PN was higher than that of RN (HR: 0.77; 95% CI: 0.65, 0.90; p = 0.002), and tumor recurrence (RR, 0.69; 95% CI: 0.53, 0.90; p = 0.007). No obvious publication bias was found in the funnel chart of the OS rates of the two groups of patients.

CONCLUSIONS

PN is beneficial for patients with T2 renal tumors in terms of OS and renal function protection. However, it is also associated with a higher risk of surgical complications.

Methylation Signature for Prediction of Progression Free Survival in Surgically Treated Clear Cell Renal Cell Carcinoma

BACKGROUND

Little is known about epigenetic silencing of genes by promoter hypermethylation in renal cell carcinoma (RCC). The aim of this study was to identify prognostic methylation markers in surgically treated clear cell RCC (ccRCC).

METHODS

Methylation patterns were assayed using the Infinium HumanMethylation450 BeadChip array on pairs of ccRCC and normal tissue from 12 patients. Using quantitative PSQ analysis, tumor-specific hypermethylated genes were validated in 25 independent cohorts and their clinical relevance was also verified in 152 independent cohorts.

RESULTS

Using genome-wide methylation array, Zinc finger protein 278 (ZNF278), Family with sequence similarity 155 member A (FAM155A) and Dipeptidyl peptidase 6 (DPP6) were selected for tumor-specific hypermethylated genes in primary ccRCC. The promoter methylation of these genes occurred more frequently in ccRCC than normal kidney in independent validation cohort. The hypermethylation of three genes were associated with advanced tumor stage and high grade tumor in ccRCC. During median follow-up of 39.2 (interquartile range, 15.4-79.1) months, 22 (14.5%) patients experienced distant metastasis. Multivariate analysis identified the methylation status of these three genes, either alone, or in a combined risk score as an independent predictor of distant metastasis.

CONCLUSION

The promoter methylation of ZNF278, FAM155A and DPP6 genes are associated with aggressive tumor phenotype and early development of distant metastasis in patients with surgically treated ccRCC. These potential methylation markers, either alone, or in combination, could provide novel targets for development of individualized therapeutic and prevention regimens.