The preoperative predictive factors for pathological T3a upstaging and positive surgical margin of clinical T1 renal cell carcinoma

OBJECTIVES

The objective of this study is predict positive surgical margin (PSM) and pathological T3a (pT3a) upstaging in patients with clinical T1 (cT1) renal cell carcinoma (RCC).

MATERIALS AND METHODS

159 patients who underwent radical nephrectomy (RN) or partial nephrectomy (PN) for RCC. Patients' demographic, laboratory, radiological and pathological data that could predict PSM and pT3a upstaging pre-operatively were evaluated. The categorical and continuous variables were compared between the patient groups with or without PSM and/or pT3a upstaging using Pearson's chi-square test, and independent samples t-test or the Mann-Whitney U test, respectively.

RESULTS

PT3a upstaging was detected in 32 (20.1%) patients, and PSM was detected in 28 (17.6%) patients. PT3a upstaging was detected in 27 and 5 patients who underwent open surgery and laparoscopic surgery, respectively (P < .001). In addition, pT3a upstaging was detected in 6 and 26 patients who underwent RN and PN, respectively (P < .001). Peritumoral fatty tissue thickness was 11.97 and 15.38 in the pT1 and pT3a patient groups, respectively (P = .022). In patients with pT3a upstaging, tumor size was larger, and renal nephrometry score and systemic immune-inflammation index (SII) were higher (P < .001, P < .001, and P = .022, respectively). It was determined that De Ritis ratio (DRR) and albumin-to-alkaline phosphatase (ALP) ratio (AAPR) parameters had significant prognostic values in predicting PSM (P = .024, and P = .001, respectively). ROC analysis indicated that tumor size predicted pT3a upstaging with 100% sensitivity and 98.6% specificity when its cut-off value was taken as 6.85 mm (AUC: 1.000, P < .001). In addition, logistic regression analysis revealed AAPR and DRR as significant predictors of PSM (P < .001, and P = .009, repsectively).

CONCLUSION

The findings of this study indicated that the surgical technique of choice and the type of operation, tumor size, RNS value, peritumoral fatty tissue thickness, HU values of peritumoral and tumor side fatty tissues, and DRR and SII values can predict pT3a upstaging of patients with cT1 RCC, and that AAPR and DRR values can predict PSM.

How to manage renal masses in kidney transplant recipients? A collaborative review by the EAU-YAU kidney transplantation and renal cancer working groups

INTRODUCTION

Kidney transplant (KT) recipients have a four-times higher risk of renal malignancies compared to general population. As these patients frequently harbor bilateral or multifocal tumors, the management of renal masses is still under debate.

OBJECTIVE

To explore the current management of the native kidney masses in KT patients.

ACQUISITION OF EVIDENCE

We performed a literature search on MEDLINE/PubMed database. A number of 34 studies were included in the present review.

SYNTHESIS OF EVIDENCE

In frail patients with renal masses below 3 cm, active surveillance is a feasible alternative. Nephron-sparing surgery is not justified for masses in the native kidney. Radical nephrectomy is the standard treatment for post-transplant renal tumors of the native kidneys in KT recipients, with laparoscopic techniques leading to significantly less perioperative complication rates as compared to the open approach. Concurrent bilateral native nephrectomy at the time of transplantation can be considered in patients with renal mass and polycystic kidney disease, especially if no residual urinary output is present. Patients with localized disease and successful radical nephrectomy do not require immunosuppression adjustment. In metastatic cases, mTOR agents can ensure efficient antitumoral response, while maintaining proper immunosuppression in order to protect the graft.

CONCLUSIONS

Post-transplant renal cancer of the native kidneys is a frequent occurrence. Radical nephrectomy is most frequently performed for localized renal masses. A standardized and widely-approved screening strategy for malignancies of native renal units is yet to be implemented.

Evolution of renal function in patients with cT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment

INTRODUCTION AND OBJECTIVES

To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for renal function impairment.

MATERIALS AND METHOD

Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m² and single renal tumor cT1, treated in our center between 2005 and 2018.

RESULTS

A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated with RN and 216 (58.1%) with PN. There was a difference of 26.75 mL/min/1.73 m² in GFR between RN and PN at discharge. Age >60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR <60 mL/min/1.73 m² at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR <45 mL/min/1.73 m² at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age >70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR <60 mL/min/1.73 m². The independent predictors for GFR <45 mL/min/1.73 m² were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001).

CONCLUSIONS

RN is a short- and long-term risk factor for CKD although with a low probability of severe CKD or ESRD in patients with preoperative GFR >60 mL/min/1.73 m². Age, DM and AHT contribute to worsening renal function during follow-up.

Evolution of renal function in patients with CT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment

INTRODUCTION AND OBJECTIVES

To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for deterioration in kidney function.

MATERIALS AND METHOD

Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m2, and single renal tumor cT1, treated in our center between 2005 and 2018.

RESULTS

A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated by RN and 216 (58.1%) by PN. There was a difference of 26.75 mL/min/1.73 m2 in GFR between RN and PN at discharge. Age > 60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR < 60 mL/min/1.73 m2 at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR < 45 mL/min/1.73m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age > 70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR < 60 mL/min/1.73 m2. The independent predictors for GFR< 45 mL/min/1.73m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001).

CONCLUSIONS

RN is a short- and long-term risk factor for CKD, although with a low probability of severe CKD or ESRD in patients with preoperative GFR > 60 mL/min/1.73 m2. Age, DM and AHT contribute to worsening renal function during follow-up.

Total renal volume and renal function after radical nephrectomy in renal neoplasm

INTRODUCTION

The reduction of renal mass after radical nephrectomy (RN) for renal neoplasm, could be associated with compensatory hypertrophy of the contralateral kidney. The capacity of compensation will determine the renal function (RF) evolution. Measuring of total renal volume (TRV) of the remaining kidney pre and post RN can help assess the RF evolution.

OBJECTIVES

To determine the correlation between TRV pre and post nephrectomy (a year of follow-up) with RF.

MATERIALS AND METHODS

A retrospective cohort study was carried out in 47 patients who had undergone RN from 2014 to 2018, due to renal cell carcinoma (confirmed by histopathology). The TRV was calculated, pre and post (a year of follow-up) RN, using ellipsoid formula equation, which were compared with clinical and analytical data. The results were analyzed by multivariate linear logistic models.

RESULTS

The median age at the time of RN was 70 years old (range, 40-88 years). Most of them were men, 66%. The estimated glomerular filtration rate (eGFR) pre and post nephrectomy was 78 (40-100) and 53.3ml/min/m² (30-90) respectively (p=0.01). The TRV pre and post-nephrectomy was 168.2ml (100.4-257.2) and 187.8ml (115.5-273.1) respectively (p=0.001). The pre-nephrectomy eGFR (β=0.62; p=0.034) and the TRV (β=1.08; p<0.0001) were positively correlated with the post-nephrectomy TRV, while the eGFR at year of follow-up was correlated negatively (β=-1.18; p=0.047).

CONCLUSIONS

The measurement of pre and post nephrectomy TRV can help to predict renal function evolution at a year of follow-up.

Total renal volume and renal function after radical nephrectomy in renal neoplasm

INTRODUCTION

The reduction of renal mass after radical nephrectomy (RN) for renal neoplasm, could be associated with compensatory hypertrophy of the contralateral kidney. The capacity of compensation will determine the renal function (RF) evolution. Measuring of total renal volume (TRV) of the remaining kidney pre and post RN can help assess the RF evolution.

OBJECTIVES

To determine the correlation between TRV pre and post nephrectomy (a year of follow-up) with RF.

MATERIALS AND METHODS

A retrospective cohort study was carried out in 47 patients who had undergone RN from 2014 to 2018, due to renal cell carcinoma (confirmed by histopathology). The TRV was calculated, pre and post (a year of follow-up) RN, using ellipsoid formula equation, which were compared with clinical and analytical data. The results were analyzed by multivariate linear logistic models.

RESULTS

The median age at the time of RN was 70 years old (range, 40-88 years). Most of them were men, 66%. The estimated glomerular filtration rate (eGFR) pre and post nephrectomy was 78 (40-100) and 53.3ml/min/ m² (30-90) respectively (P=.01). The TRV pre and post-nephrectomy was 168.2ml (100.4-257.2) and 187.8ml (115.5-273.1) respectively (P=.001). The pre-nephrectomy eGFR (β=0.62; P=.034) and the TRV (β=1.08; P<.0001) were positively correlated with the post-nephrectomy TRV, while the eGFR at year of follow-up was correlated negatively (β=-1.18; P=.047) CONCLUSIONS: The measurement of pre and post nephrectomy TRV can help to predict renal function evolution at a year of follow-up.

Changing patterns in the surgical management of renal masses

OBJECTIVE

To describe the temporal trends in surgical techniques for the management of renal masses at a single Spanish academic institution and identify factors associated with partial nephrectomy (PN) decision.

MATERIALS AND METHODS

A total of 646 patients were treated by surgery for clinically localised renal masses from January 2004 to December 2012 at a tertiary referral center. Surgical techniques included open radical nephrectomy (RN), open PN, laparoscopic RN, and laparoscopic PN. Descriptive statistics were used to compare baseline characteristics and proportions of patients treated by different surgical techniques. Annual trends in the proportion of procedures performed were determined. Adjusted odds ratios (OR) and 95% confidence intervals were calculated to evaluate clinical variables predictive of PN.

RESULTS

During the 9-year study period, the proportion of PN relative to RN increased from 21% to 55%. With regard to surgical approach, open procedures for both RN and PN decreased gradually in favor of minimally invasive approaches (83% in 2004 to 4% in 2011-2012). While median tumor size did not significantly change over the study period, laparoscopic PN became the most commonly performed kidney procedure in 2011-2012 (49% of all procedures). Clinical variables independently predictive of partial nephrectomy were ASA score, baseline renal function and tumor size (all P<.05).

CONCLUSIONS

At our academic institution, temporal trends in the management of renal masses have established PN as the most common surgical option. Although PN was increasingly used over the study period, a parallel increase in minimally invasive approaches for RN and PN was seen.

The best option: Umbilical LESS radical nephrectomy with vaginal extraction

INTRODUCTION

Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages.

PATIENT AND METHOD

We present a 34-year-old patient with a solid mesorenal lesion measuring 8 cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instrument's double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision.

RESULTS

After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bag's thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180 min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications.

CONCLUSIONS

Umbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result.