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

Clear cell likelihood score may improve diagnosis and management of renal masses

The detection of solid renal masses has increased over time due to incidental findings during imaging studies conducted for unrelated medical conditions. Approximately 20% of lesions measuring less than 4 cm are benign and 80% are malignant. Clear cell renal cell carcinoma (ccRCC) is the most frequent among renal carcinomas, responsible for 65-80% of cases. The increased detection of renal masses facilitates early diagnosis and treatment. However, it also leads to more invasive interventions, which result in higher morbidity and costs. Currently, only histological analysis can offer an accurate diagnosis. Surgical nephron loss significantly elevates morbidity and mortality rates. Active surveillance represents a conservative management approach for patients diagnosed with a solid renal mass that is endorsed by both American Urological Association and the European Society for Medical Oncology. However, active surveillance is used in a minority of patients and varies across institutions. The lack of clinical studies using a standardized approach to incidentally detected small renal masses precludes the widespread use of active surveillance. Hence, there is an urgent need for better patient selection, distinguishing those who require surgery from those suitable for active surveillance. The clear cell likelihood score (ccLS) represents a novel MRI tool for assessing the probability of a renal mass being a ccRCC. In this study, we present a comprehensive review of renal masses and their evaluation using the ccLS to facilitate shared decision between urologists and patients.

French AFU Cancer Committee Guidelines - Update 2024-2026: Management of kidney cancer

OBJECTIVE

To update the French recommendations for the management of kidney cancer.

METHODS

A systematic review of the literature was conducted for the period from 2014 to 2024. The most relevant articles concerning the diagnosis, classification, surgical treatment, medical treatment, and follow-up of kidney cancer were selected and incorporated into the recommendations. The recommendations have been updated specifying the level of evidence (strong or weak).

RESULTS

Kidney cancer following prolonged occupational exposure to trichloroethylene should be considered an occupational disease. The reference examination for the diagnosis and staging of kidney cancer is the contrast-enhanced thoraco-abdominal CT scan. PET scans are not indicated in the staging of kidney cancer. Percutaneous biopsy is recommended in situations where its results will influence therapeutic decisions. It should be used to reduce the number of surgeries for benign tumors, particularly avoiding unnecessary radical nephrectomies. Kidney tumors should be classified according to the pTNM 2017 classification, the WHO 2022 classification, and the ISUP nucleolar grade. Metastatic kidney cancers should be classified according to IMDC criteria. Surveillance of tumors smaller than 2cm should be prioritized and can be offered regardless of patient age. Robot-assisted laparoscopic partial nephrectomy is the reference surgical treatment for T1 tumors. Ablative therapies and surveillance are options for elderly patients with comorbidities for tumors larger than 2cm. Stereotactic radiotherapy is an option to discuss for treating localized kidney tumors in patients not eligible for other treatments. Radical nephrectomy is the first-line treatment for locally advanced localized cancers. Pembrolizumab is recommended for patients at high risk of recurrence after surgery for localized kidney cancer. In metastatic patients, cytoreductive nephrectomy can be immediate in cases of good prognosis, delayed in cases of intermediate or poor prognosis for patients stabilized by medical treatment, or as "consolidation" in patients with complete or major partial response at metastatic sites after systemic treatment. Surgical or local treatment of metastases can be proposed for single lesions or oligometastases. Recommended first-line drugs for metastatic clear cell renal carcinoma are combinations of axitinib/pembrolizumab, nivolumab/ipilimumab, nivolumab/cabozantinib, and lenvatinib/pembrolizumab. Patients with non-clear cell metastatic kidney cancer should be presented to the CARARE Network and prioritized for inclusion in clinical trials.

CONCLUSION

These updated recommendations are a reference that will enable French and French-speaking practitioners to optimize their management of kidney cancer.

Targeting the Adenosine A2A Receptor as a Novel Therapeutic Approach for Renal Cell Carcinoma: Mechanisms and Clinical Trial Review

Renal cell carcinoma (RCC) accounts for nearly 2% of cancers diagnosed worldwide. For metastatic RCC, targeted therapy is one of the most common treatment methods. It can include approaches that target vascular endothelial growth factor (VEGFR) or rely on immune checkpoint inhibitors or mTOR inhibitors. Adenosine A2A receptor (A2AR) is a type of widely distributed G-protein-coupled receptor (GPCR). Recently, an increasing number of studies suggest that the activation of A2AR can downregulate anti-tumor immune responses and prevent tumor growth. Currently, the data on A2AR antagonists in RCC treatment are still limited. Therefore, in this article, we further investigate the clinical trials investigating A2AR drugs in RCC. We also describe the epidemiology and current treatment of RCC, along with the physiological role of A2AR, and the types of A2AR drugs that are associated with tumor treatment.

Comparison of Outcomes Between Partial and Radical Laparoscopic Nephrectomy for Localized Renal Tumors Larger Than Four Centimeters: A Systematic Review and Meta-Analysis

Background

Earlier studies have juxtaposed different laparoscopic methods for treating renal tumors; however, extensive evidence with a particular focus on large kidney tumors remains lacking. The objective of this meta-analysis was to assess the perioperative outcomes, kidney performance, and cancer-related results of laparoscopic partial nephrectomy (LPN) versus laparoscopic radical nephrectomy (LRN) for treating extensive, localized, non-metastatic kidney tumors (cT1b-cT2N0M0).

Methods

We systematically searched multiple databases from database inception until December 2023 for relevant studies. Selected data were analyzed with the Cochrane Collaboration's Review Manager 5.4 software using a random-effects model. Outcomes were expressed as odds ratios and weighted mean differences with 95% confidence intervals, considering a P value of < 0.05 as significant.

Results

Data from nine studies encompassing 1,303 patients (529 LPN, 774 LRN) revealed that LPN was associated with lengthier surgeries and increased blood loss compared to LRN. While LPN exhibited higher postoperative complication rates, the disparity did not reach statistical significance. LPN led to improved postoperative renal function, manifesting as a reduced estimated glomerular filtration rate (eGFR) decline and fewer incidents of new chronic kidney disease cases. Both groups demonstrated comparable tumor recurrence and overall mortality rates, but LPN exhibited significantly lower cancer-specific mortality rates.

Conclusions

LPN, despite longer operative times and greater intraoperative blood loss, was found to be superior to LRN in preserving postoperative renal function. Oncologically, LPN and LRN have comparable overall mortality rates, but LPN showed a significant advantage in terms of lower cancer-specific mortality rates.

Renal functional outcomes after nephrectomy in patients with localized renal cell carcinoma and diabetes mellitus: a systematic review and meta-analysis

INTRODUCTION AND OBJECTIVE

Diabetes mellitus (DM), one of the most common comorbidities in patients with renal cell carcinoma (RCC), was proven to be an important prognostic factor of overall survival for these patients. Regarding the influence on renal function after nephrectomy, evidence is still scant. This systematic review and meta-analysis was conducted to provide a more reliable analysis of the association between DM and long-term renal functional outcomes after nephrectomy.

METHODS

The PubMed, Web of Science, Embase and Cochrane Library (CENTRAL) databases were searched for eligible studies from inception to January 2023. Hazard ratios (HRs) with 95% confidence intervals (CIs) were extracted to evaluate the association between DM and renal functional outcomes using a random effects model. Stata 17.0 software was used for statistical analysis.

RESULTS

The meta-analysis included thirteen studies consisting of 8562 RCC patients who underwent nephrectomy. Preoperative comorbidity of DM was significantly associated with poor renal functional outcomes (HR = 1.91, 95% CI 1.48-2.48, p < 0.0001), regardless of ethnicity, follow-up time, body mass index (BMI) and age. However, in the radical nephrectomy subgroup, DM was not significantly associated with renal function decline (HR = 1.91, 95% CI 0.93-3.90, p = 0.0781).

CONCLUSIONS

The aggregate evidence indicated that preexisting DM may be associated with poor renal functional outcomes in patients with RCC after nephrectomy, especially in patients receiving partial nephrectomy. Urologists should focus more on the glycemic management of these patients after nephrectomy. More high-quality studies are needed to explore the influence of DM on renal function outcomes in postoperative patients.

Risk factors of recurrence after robot-assisted laparoscopic partial nephrectomy for solitary localized renal cell carcinoma

To evaluate the recurrence rate and risk factors of recurrence after robot-assisted laparoscopic partial nephrectomy for solitary renal cell carcinoma (RCC). A total of 1265 cases of initial solitary localized RCC were analyzed. The baseline characteristics, complexity (REANL nephrometry score), intra- and peri-operative outcomes, and recurrence were evaluated. Logistic regression was performed to evaluate the factors affecting recurrence after RAPN for solitary localized RCC. Recurrence after robot-assisted partial nephrectomy (RAPN) occurred in 29 patients (2.29%). The median follow-up was 36.0 months. The N domain (nearness to collecting system/sinus) (odd ratio (OR) 3.517, 95% confidence interval (CI) 1.557-7.945, p = 0.002), operation time (OR 1.005, 95% CI 1.001-1.010, p = 0.013), and perioperative transfusion (OR 5.450, 95% CI 1.197-24.816, p = 0.028) affected recurrence. Distant metastasis among patients with recurrence was significantly associated with nearness to the collecting system/sinus (OR 2.982, 95% CI 1.162-7.656, p = 0.023) and distance between the mass and collecting system/sinus (OR 0.758, 95% CI 0.594-0.967, p = 0.026). Nearness to the collecting system/sinus, operation time, and perioperative transfusion affect recurrence after RAPN for solitary localized RCC. Moreover, the proximity to the collecting system/sinus and distance between the mass and collecting system/sinus were significantly related to distant metastasis after RAPN.

Laser speckle contrast imaging compared with indocyanine green in renal perfusion of a porcine model

Background

When viewed under near-infrared light, indocyanine green (ICG) signal for kidney perfusion can be utilized in partial nephrectomy. Laser speckle contrast imaging (LSCI) uses coherent light to detect perfusion during real-time laparoscopic surgery.

Materials and methods

Laser speckle contrast imaging or ActivSight, an imaging sensor adapter, was used during laparoscopy of an anesthetized porcine kidney model. ActivSight's "perfusion mode" and "quantification mode" displayed the blood flow as a heatmap and numerical signal intensity, respectively.

Results

After the upper segmental renal artery was clamped, ICG was seen in the lower pole, and LSCI showed low unit (dark color) quantification and perfusion in the upper pole. Indocyanine green was retained in the lower pole after the upper segmental artery was unclamped, and LSCI perfusion was demonstrated in the entire kidney.

Conclusions

Laser speckle contrast imaging is a dye-free, repeatable, real-time adjunct for renal parenchymal perfusion assessment applicable to minimally invasive renal surgery to complement the technology of ICG near-infrared fluorescence and advance digital surgery.

Treatment strategies for clear cell renal cell carcinoma: Past, present and future

Clear cell renal cell carcinoma (ccRCC) is the most prevalent histological subtype of kidney cancer, which is prone to metastasis, recurrence, and resistance to radiotherapy and chemotherapy. The burden it places on human health due to its refractory nature and rising incidence rate is substantial. Researchers have recently determined the ccRCC risk factors and optimized the clinical therapy based on the disease's underlying molecular mechanisms. In this paper, we review the established clinical therapies and novel potential therapeutic approaches for ccRCC, and we support the importance of investigating novel therapeutic options in the context of combining established therapies as a research hotspot, with the goal of providing diversified therapeutic options that promise to address the issue of drug resistance, with a view to the early realization of precision medicine and individualized treatment.

Patient Factors Impacting Perioperative Outcomes for T1b-T2 Localized Renal Cell Carcinoma May Guide Decision for Partial versus Radical Nephrectomy

There remains debate surrounding partial (PN) versus radical nephrectomy (RN) for T1b-T2 renal cell carcinoma (RCC). PN offers nephron-sparing benefits but involves increased perioperative complications. RN putatively maximizes oncologic benefit with complex tumors. We analyzed newly available nephrectomy-specific NSQIP data to elucidate predictors of perioperative outcomes in localized T1b-T2 RCC. We identified 2094 patients undergoing nephrectomy between 2019-2020. Captured variables include surgical procedure and approach, staging, comorbidities, prophylaxis, peri-operative complications, reoperations, and readmissions. 816 patients received PN while 1278 received RN. Reoperation rates were comparable; however, PN patients more commonly experienced 30-day readmissions (7.0% vs. 4.7%, p = 0.026), bleeds (9.19% vs. 5.56%, p = 0.001), renal failure requiring dialysis (1.23% vs. 0.31%, p = 0.013) and urine leak or fistulae (1.10% vs. 0.31%, p = 0.025). Infectious, pulmonary, cardiac, and venothromboembolic event rates were comparable. Robotic surgery reduced occurrence of various complications, readmissions, and reoperations. PN remained predictive of all four complications upon multivariable adjustment. Several comorbidities were predictive of complications including bleeds and readmissions. This population-based cohort explicates perioperative outcomes following nephrectomy for pT1b-T2 RCC. Significant associations between PN, patient-specific factors, and complications were identified. Risk stratification may inform management to improve post-operative quality of life (QOL) and RCC outcomes.

Partial Nephrectomy for T1b/T2 Renal Mass: An Added Shift from Radical Nephrectomy

The aim of our study was to show our short-term experience in managing large renal masses (cT1b/T2) through partial nephrectomy (PN) over the last 3 years. Retrospective data collection for all patients managed by PN for renal masses larger than 4 cm over the last 3 years. Epidemiological data were collected. Surgical data including surgical and ischemic times as well as intra and postoperative complications were collected. Pre- and postoperative estimated glomerular filtration rate (eGFR) data were collected and correlated as well as postoperative complications and recurrence. We could identify 47 patients managed by PN for radiologically confirmed >4 cm renal masses. The mean age of the patients was 55.7 ± 13.4, including 29 males and 18 females. Masses were T1b and T2 in 40 and 7 patients, respectively. The mean tumor size was 6.2 ± 1.5 cm. Using renal nephrometry score; 8, 28, and 11 had low, moderate, and high complexity, respectively. Renal cell carcinoma (RCC) was identified in 42 patients. Five patients out of 42 cancerous cases (12%) had pathological T3 RCC. The mean preoperative and postoperative eGFR were 89.09 ± 12.41 and 88.50 ± 10.50, respectively (P 0.2). The median follow-up was 14 months and within that short time, no patient had evidence for cancer recurrence. PN for large renal masses is safe in experienced hands and should be attempted in a higher percentage of patients, regardless of the tumor complexity. No cancer recurrence or deterioration of renal function was observed within our short-term follow-up.