Robotic-assisted laparoscopic partial nephrectomy vs. laparoscopic and open partial nephrectomy: A single-site, two-surgeon, retrospective cohort study.

INTRODUCTION: In 2019, our center attempted to transition all partial nephrectomies (PNs) to robotic-assisted laparoscopic PN (RALPN). The purpose of this study was to compare RALPN outcomes to laparoscopic PN (LPN) and open PN (OPN) at our institution, as there is limited literature from Canadian centers. METHODS: In this single-center, two-surgeon, retrospective cohort study, we compared RALPN outcomes during the early phase of our robotics program to OPN and LPN performed just before the introduction of RALPN. RESULTS: A total of 106 patients underwent OPN, 83 LPN, and 82 RALPN during the study period. Median RALPN RENAL score was 7 vs. 6 for LPN (p<0.05) and 8 for OPN (p=0.10). Median RALPN length of stay (LOS) was two days vs. three and four days for LPN and OPN (p<0.05), respectively. OPN median procedure time was 104 minutes vs. 94 and 82 minutes for LPN and RALPN (p<0.05), respectively. Median OPN operating room (OR) time was 160 minutes vs. 150 and 146 minutes for LPN and RALPN (p<0.05), respectively. There were no significant differences in intraoperative (p=0.92) or postoperative complications rates (p=0.47). RALPN warm ischemia time (WIT) was 17 minutes vs 14.5 and 15 minutes for OPN and LPN (p<0.05), respectively. Median RALPN estimated blood loss (EBL) was 165 ml vs. 250 ml for OPN (p<0.05) and 125 ml for LPN (p=0.15). CONCLUSIONS: Although patients who underwent RALPN had longer WIT, they had similar rates of complications, required less total OR time, and had shorter procedure time and LOS compared with OPN and LPN despite similar RENAL score compared to OPN and greater score than LPN.

A comparison of the sarcopenic effect of androgen receptor-axis-targeted agents vs. androgen deprivation alone in patients with metastatic prostate cancer.

INTRODUCTION: Androgen deprivation therapy (ADT) with androgen receptor axis-targeted (ARAT) therapy is the standard of care provided to patients with metastatic prostate cancer. While effective, it results in sequelae, such as loss of skeletal muscle mass. In this study, we compared the sarcopenic effects of abiraterone and enzalutamide, two ARATs used to treat metastatic prostate cancer. METHODS: Our cohort was comprised of 55 patients diagnosed with metastatic hormonenaive prostate cancer from 2014-2019. Patients were divided into three treatment groups: gonadotropin-releasing hormone (GnRH ) agonist alone; GnRH agonist combined with abiraterone acetate; and GnRH agonist combined with enzalutamide. We then compared axial computed tomographic (CT) scans at the L3 level before and after the initiation of hormone therapy for each patient. A skeletal muscle index (SMI) was calculated for each patient, and alongside clinical data, was compared between the three groups. One-way analysis of variance (ANOVA) and Fisher's exact test were used to compare means and proportions, respectively. RESULTS: Baseline clinical characteristics were not significantly different between the three groups. The percent SMI change and number of newly sarcopenic patients were not found to be significantly different between the groups. The only variable that was significantly different across the three groups was time between CT scans. CONCLUSIONS: Although we found no significant difference in the sarcopenic effects of GnRH alone, GnRH with abiraterone, or GnRH with enzalutamide in our cohort of 55 hormone-naive metastatic prostate cancer patients, overall decreases in muscle mass were observed for all three groups. This highlights the importance of muscle-retaining strategies for patients undergoing ADT for metastatic prostate cancer, regardless of therapeutic regimen.

Examining the impact of postoperative opioid use on length of hospital stay following radical cystectomy.

INTRODUCTION: Radical cystectomy (RC) is associated with high rates of morbidity, prolonged hospital stay, and increased opioid use for postoperative pain management; however, the relationship between postoperative opioid use and length of stay (LOS ) remains uncharacterized. This study serves to investigate the association between postoperative opioid use and length of hospital stay after RC. The relationship between patient and surgical factors on LOS was also characterized. METHODS: We retrospectively reviewed all patients between 2009 and 2019 who underwent RC at our institution. Patient and perioperative variables were analyzed to determine the relationship between postoperative opioid use and LOS using multivariable linear regression analysis. RESULTS: We identified 240 patients for study inclusion with a median age of 70.0 years. Median LOS was 10.0 days, with median daily mg morphine equivalent use of 57.5 for patients. Daily mg morphine equivalent use was significantly associated with an increased LOS, as were previous pelvic radiation, postoperative ileus, and higher Clavien-Dindo grade complication during admission (all p<0.05). Median LOS increased by one day for each increase of 13.2 daily mg morphine equivalents received. CONCLUSIONS: Increased daily opioid use was associated with increased length of hospital stay after RC. Non-opioid-based pain management approaches may be effective in reducing LOS after RC.

Psychosocial Distress in Adult Patients Awaiting Cancer Surgery during the COVID-19 Pandemic.

Cancer causes substantial emotional and psychosocial distress, which may be exacerbated by delays in treatment. The COVID-19 pandemic has resulted in increased wait times for many patients with cancer. In this study, the psychosocial distress associated with waiting for cancer surgery during the pandemic was investigated. This cross-sectional, convergent mixed-methods study included patients with lower priority disease during the first wave of COVID-19 at an academic, tertiary care hospital in eastern Canada. Participants underwent semi-structured interviews and completed two questionnaires: Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS). Qualitative analysis was completed through a thematic analysis approach, with integration achieved through triangulation. Fourteen participants were recruited, with cancer sites including thyroid, kidney, breast, prostate, and a gynecological disorder. Increased anxiety symptoms were found in 36% of patients and depressive symptoms in 14%. Similarly, 64% of patients experienced moderate or high stress. Six key themes were identified, including uncertainty, life changes, coping strategies, communication, experience, and health services. Participants discussed substantial distress associated with lifestyle changes and uncertain treatment timelines. Participants identified quality communication with their healthcare team and individualized coping strategies as being partially protective against such symptoms. Delays in surgery for patients with cancer during the COVID-19 pandemic resulted in extensive psychosocial distress. Patients may be able to mitigate these symptoms partially through various coping mechanisms and improved communication with their healthcare teams.

Creation of a primary tumor tissue expression biomarker-augmented prognostic model for patients with metastatic renal cell carcinoma.

BACKGROUND: Clinical and pathological factors alone have limited prognostic ability in patients with metastatic clear cell renal cell carcinoma (ccRCC). Bim, a downstream pro-apoptotic molecule in the PD-1 signaling pathway, has recently been associated with survival in other malignancies. We sought to determine if tissue biomarkers including Bim, added to a previously reported clinical metastases score, improved prediction of cancer-specific survival (CSS) for patients with metastatic ccRCC. METHODS: Patients with metastatic ccRCC who underwent nephrectomy between 1990 and 2004 were identified using our institutional registry. Sections from paraffin-embedded primary tumor tissue blocks were used for immunohistochemistry staining for Bim, PD-1, B7-H1 (PD-L1), B7-H3, CA-IX, IMP3, Ki67, and survivin. Biomarkers that were significantly associated with CSS after adjusting for the metastases score were used to develop a biomarker-specific multivariable model using a bootstrap resampling approach and forward selection. Predictive ability was summarized using a bootstrap-corrected c-index. RESULTS: The cohort included 602 patients: 192 (32%) with metastases at diagnosis and 410 (68%) who developed metastases after nephrectomy. Median follow-up was 9.6 years (IQR 4.2-12.8), during which 504 patients died of RCC. Bim, IMP3, Ki67, and survivin expression were significantly associated with CSS after adjusting for the metastases score, and were eligible for biomarker-specific model inclusion. After variable selection, high Bim (hazard ratio [HR] = 1.44; 95% confidence interval [CI] 1.16-1.78; P <0.001), high survivin (HR = 1.35; 95% CI 1.08-1.68; P = 0.008), and the metastases score (HR = 1.13 per 1 point; 95% CI 1.10-1.16; P <0.001) were retained in the final multivariable model (c-index = 0.69). CONCLUSION: We created a prognostic model combining the clinical metastases score and 2 primary tumor tissue expression biomarkers, Bim and survivin, for patients with metastatic renal cell carcinoma who underwent nephrectomy.

Rare case of upper urinary tract squamous cell carcinoma presenting with significant paraneoplastic syndrome.

Squamous cell carcinoma of the upper urinary tract is a rare entity associated with rapidly progressive disease and poor outcomes. Here, we describe a case of a squamous cell carcinoma of the upper urinary tract associated with significant progression and paraneoplastic syndrome. Post-operatively, the patient had near complete resolution of her paraneoplastic syndromes with significant improvements in her functional status.

Survival outcomes for patients with surgically induced end-stage renal disease.

INTRODUCTION: While medically induced end-stage renal disease (m-ESRD) has been well-studied, outcomes in patients with surgically induced ESRD (s-ESRD) are unknown. We sought to quantitatively compare the non-oncological outcomes for s-ESRD and m-ESRD in a large, population-based cohort. METHODS: Medicare patients >65 years old initiating hemodialysis were identified using the U.S. Renal Data System database (2000-2012). Metastatic cancer, prior transplant history, and nephrectomy for polycystic kidney disease were exclusion criteria. Patients were classified as having s-ESRD or m-ESRD based on hospital and physician claims for nephrectomy within a year preceding the onset of maintenance hemodialysis. Outcomes included non-cancer mortality (NCM), overall survival (OS), cardiovascular event (CVE), and renal transplantation. Time-to-event analyses were performed using Kaplan-Meier and cumulative incidence curves, and multivariable Cox and Fine-and-Grey regression models. RESULTS: The cohort included 312 612 patients, of whom 1648 (0.53%) had s-ESRD. Compared to m-ESRD patients, s-ESRD patients had a significantly lower five-year cumulative incidence of NCM (68% vs. 80%; p<0.001) and CVE (62% vs. 68%; p<0.001), with a correspondingly higher probability of OS (22% vs. 17%; p<0.001) and rate of renal transplantation (3.6% vs. 2.0%; p<0.001). On multivariable analyses, s-ESRD remained associated with lower risks of NCM (p<0.001) and CVE (p<0.001), improved OS (p<0.001), and higher chance of renal transplantation (p<0.001). CONCLUSIONS: While outcomes for s-ESRD appear more favorable than m-ESRD, s-ESRD is still associated with a substantial risk of NCM and CVE, and a low incidence of renal transplantation in Medicare patients >65 years old. These non-oncological outcomes are worth considering in patients potentially facing postoperative ESRD.

Extended Duration of Active Surveillance of Small Renal Masses: A Prospective Cohort Study.

PURPOSE: We report the natural history of small renal masses in patients undergoing active surveillance with extended followup. MATERIALS AND METHODS: We performed a prospective cohort study in patients undergoing active surveillance of small renal masses diagnosed between 2001 and 2011 at a single institution. All patients underwent active surveillance of small renal masses presumed to be renal cell carcinoma based on diagnostic imaging. Reported patient outcomes included progression to treatment, metastatic disease and/or death. Linear and volumetric tumor growth rates were evaluated. RESULTS: Included in study were 103 patients with a total of 107 small renal masses. Median followup was 55.5 months in patients who continued on active surveillance. Median maximum diameter and volume at diagnosis were 2.1 cm (IQR 1.5-2.7) and 4.8 cm3 (IQR 1.7-11.9), respectively. At last followup 53 patients (51.5%) were alive without metastatic disease, 48 (45.6%) had died of another cause and metastatic disease had developed in 2 (1.9%), including 1 (1.0%) who ultimately died of metastatic renal cell carcinoma. The mean ± SEM linear and volumetric growth rates of all small renal masses were 0.21 ± 0.03 cm per year and 6.15 ± 2.15 cm3, respectively. Study limitations include nonstandardized followup and a lack of biopsy data on most patients. CONCLUSIONS: During extended followup the majority of small renal masses in patients on active surveillance display indolent behavior. The risk of progression to metastatic disease remains low.

Trends and disparities in the use of neoadjuvant chemotherapy for muscle-invasive urothelial carcinoma.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) prior to radical or partial cystectomy is considered the standard of care for eligible patients with muscle-invasive urothelial carcinoma. Despite guideline recommendations, adoption of NAC has historically been low, although prior studies have suggested that use is increasing. In this contemporary study, we examine trends in the use of NAC and explore factors associated with its receipt. METHODS: We identified patients in the National Cancer Database who underwent radical or partial cystectomy for cT2-cT4N0M0 urothelial carcinoma from 2006-2014. The proportion of patients receiving NAC during each year was examined. Logistic regression models were used to evaluate clinical and socioeconomic factors associated with the receipt of NAC. RESULTS: A total of 18 188 patients were identified who underwent radical or partial cystectomy for muscle-invasive bladder cancer. Overall, 3940 (21.7%) received NAC. We noted a significant increase in the use of NAC over time, from 9.7% in 2006 to 32.2% in 2014. Factors associated with lower use of NAC include older age, higher comorbidity score, lower cT stage, lower hospital radical cystectomy volume, treatment at a non-academic facility, lower patient income, and receipt of partial cystectomy (all p<0.001). Interestingly, neither sex nor race were associated with receipt of NAC. CONCLUSIONS: Use of NAC has increased significantly over time to a modest rate of 32%. However, disparities still exist in the receipt of NAC, and future efforts aimed at mitigating these disparities are warranted.

Predicting Renal Function Outcomes After Partial and Radical Nephrectomy.

BACKGROUND: Partial nephrectomy (PN) is generally favored for cT1 tumors over radical nephrectomy (RN) when technically feasible. However, it can be unclear whether the additional risks of PN are worth the magnitude of renal function benefit. OBJECTIVE: To develop preoperative tools to predict long-term estimated glomerular filtration rate (eGFR) beyond 30d following PN and RN, separately. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, patients who underwent RN or PN for a single nonmetastatic renal tumor between 1997 and 2014 at our institution were identified. Exclusion criteria were venous tumor thrombus and preoperative eGFR <15ml/min/1.73m2. INTERVENTION: RN and PN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Hierarchical generalized linear mixed-effect models with backward selection of candidate preoperative features were used to predict long-term eGFR following RN and PN, separately. Predictive ability was summarized using marginal RGLMM2, which ranges from 0 to 1, with higher values indicating increased predictive ability. RESULTS AND LIMITATIONS: The analysis included 1152 patients (13 206 eGFR observations) who underwent RN and 1920 patients (18 652 eGFR observations) who underwent PN, with mean preoperative eGFRs of 66ml/min/1.73m2 (standard deviation [SD]=18) and 72ml/min/1.73m2 (SD=20), respectively. The model to predict eGFR after RN included age, diabetes, preoperative eGFR, preoperative proteinuria, tumor size, time from surgery, and an interaction between time from surgery and age (marginal RGLMM2=0.41). The model to predict eGFR after PN included age, presence of a solitary kidney, diabetes, hypertension, preoperative eGFR, preoperative proteinuria, surgical approach, time from surgery, and interaction terms between time from surgery and age, diabetes, preoperative eGFR, and preoperative proteinuria (marginal RGLMM2). Limitations include the lack of data on renal tumor complexity and the single-center design; generalizability needs to be confirmed in external cohorts. CONCLUSIONS: We developed preoperative tools to predict renal function outcomes following RN and PN. Pending validation, these tools should be helpful for patient counseling and clinical decision-making. PATIENT SUMMARY: We developed models to predict kidney function outcomes after partial and radical nephrectomy based on preoperative features. This should help clinicians during patient counseling and decision-making in the management of kidney tumors.

Systematic Review of the Role of Cytoreductive Nephrectomy in the Targeted Therapy Era and Beyond: An Individualized Approach to Metastatic Renal Cell Carcinoma.

CONTEXT: The role of cytoreductive nephrectomy (CN) in the management of metastatic renal cell carcinoma (mRCC) in the targeted therapy (TT) era is controversial. OBJECTIVE: To assess if CN versus no CN is associated with improved overall survival (OS) in patients with mRCC treated in the TT era and beyond, characterize the morbidity of CN, identify prognostic and predictive factors, and evaluate outcomes following treatment sequencing. EVIDENCE ACQUISITION: Medline, EMBASE, and Cochrane databases were searched from inception to June 4, 2018 for English-language clinical trials, cohort studies, and case-control studies evaluating patients with mRCC who underwent and those who did not undergo CN. The primary outcome was OS. Risk of bias was evaluated using the Cochrane Collaborative tools. EVIDENCE SYNTHESIS: We identified 63 reports on 56 studies. Risk of bias was considered moderate or serious for 50 studies. CN was associated with improved OS among patients with mRCC in 10 nonrandomized studies, while one randomized trial (CARMENA) found that OS with sunitinib alone was noninferior to that with CN followed by sunitinib. The risk of perioperative mortality and Clavien ≥3 complications ranged from 0% to 10.4% and from 3% to 29.4%, respectively, with no meaningful differences between upfront CN or CN after presurgical systemic therapy (ST). Notably, 12.9-30.4% of patients did not receive ST after CN. Factors most consistently prognostic of decreased OS were progression on presurgical ST, high C-reactive protein, high neutrophil-lymphocyte ratio, poor International Metastatic renal cell carcinoma Database Consortium (IMDC)/Memorial Sloan Kettering Cancer Center (MSKCC) risk classification, sarcomatoid dedifferentiation, and poor performance status. At the same time, good performance status and good/intermediate IMDC/MSKCC risk classification were most consistently predictive of OS benefit with CN. In a randomized trial investigating the sequence of CN and ST (SURTIME), an OS trend was observed with CN after a period of ST in patients without progression compared with upfront CN. However, the study was underpowered and results are exploratory. CONCLUSIONS: Currently, ST should be prioritized in the management of patients with de novo mRCC who require medical therapy. CN maintains a role in patients with limited metastatic burden amenable to surveillance or metastasectomy, and may potentially be considered in patients with favorable response after initial ST or for symptom's palliation. PATIENT SUMMARY: In the contemporary era, receiving systemic therapy is the priority in metastatic kidney cancer. Nephrectomy still has a role in patients with limited burden of metastases, well-selected patients based on established prognostic and predictive factors, and patients with a favorable response after initial systemic therapy.

The Probability of Aggressive Versus Indolent Histology Based on Renal Tumor Size: Implications for Surveillance and Treatment.

BACKGROUND: While the probability of malignant versus benign histology based on renal tumor size has been described, this alone does not sufficiently inform decision-making in the modern era since indolent malignant tumors can be managed with active surveillance. OBJECTIVE: To characterize the probability of aggressive versus indolent histology based on radiographic tumor size. DESIGN, SETTING, AND PARTICIPANTS: We evaluated patients who underwent radical or partial nephrectomy at Mayo Clinic for a pT1-2, pNx/0, M0 solid renal tumor between 1990 and 2010. Pathology was reviewed by one genitourinary pathologist. High-grade clear-cell renal cell carcinoma (RCC), high-grade papillary RCC, collecting duct RCC, translocation-associated RCC, hereditary leiomyomatosis RCC, unclassified RCC, and malignant non-RCC tumors were all considered aggressive, as well as any tumors demonstrating coagulative necrosis (except low-grade papillary RCC) or sarcomatoid differentiation. The remaining benign and malignant tumors were considered indolent. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cancer-specific survival (CSS) was estimated using the Kaplan-Meier method. Logistic regression models were used to estimate the probability of malignant and aggressive histology based on tumor size. Sex-stratified analyses were also performed. RESULTS AND LIMITATIONS: Of the 2650 patients included, there were 1860 patients with indolent tumors (300 benign; 1560 malignant) and 790 with aggressive tumors. The 10-yr CSS was 96% for indolent malignant tumors and 81% for aggressive malignant tumors. The predicted percentages of any malignant histology as well as aggressive histology increased with tumor size. Specifically, 2cm, 3cm, and 4cm tumors have an estimated 84%, 87%, and 88% likelihood of malignancy, respectively, and an 18%, 24%, and 29% likelihood of aggressive histology, respectively. For any given tumor size, men had a greater chance of aggressive histology than women. Potential limitations of this observational surgical cohort include selection bias. CONCLUSIONS: We present tumor size-based estimates of the probability of aggressive histology for renal masses. This information should be useful for initial patient counseling and management. PATIENT SUMMARY: Active surveillance is an option for kidney masses, even if they are malignant. Beyond knowing whether the mass is benign or cancer, it is important to know whether or not it is an aggressive tumor. This study presents tumor size-specific and sex-specific estimates of the probability of cancer overall and aggressive cancer among patients with a kidney mass in order to aid with initial decision-making.

Synchronous nephron-sparing approaches for bilateral renal masses: peri-operative and renal functional outcomes.

OBJECTIVES: To evaluate the peri-operative and renal functional outcomes of patients undergoing synchronous bilateral partial nephrectomy (PN) or percutaneous cryoablation (PCA). PATIENTS AND METHODS: We retrospectively reviewed our institutional nephrectomy and renal mass ablation registries to identify all patients with synchronous bilateral renal masses who underwent simultaneous bilateral PN (n = 76) or PCA (n = 13) between 1974 and 2013. Changes in estimated glomerular filtration rate (eGFR) as well as peri-operative complications are descriptively reported for each procedure. RESULTS: The number of treated renal masses in the 76 patients in the PN group and the 13 patients in the PCA group was 249 and 28, respectively. The median (interquartile range [IQR]) age at treatment was 62 (50, 71) years for the PN group and 67 (56, 72) for the PCA group. The median (IQR) maximum tumour sizes were 4.6 (3.4, 6.5) cm and 2.6 (2.4, 3.2) cm for the PN and PCA groups, respectively. The median (IQR) length of hospital stay was 7 (5, 8) days for the PN group and 1 (1, 10) days for the PCA group. The median (IQR) change in eGFR from baseline to discharge was -32 (-46, -15)% for the PN group and -17% (-33, -3) for the PCA group. By 3 months, median (IQR) renal function improved, with changes of -9 (-19, 0)% and -8 (-11, 15)%, respectively, compared with baseline. No patient in either group required renal replacement therapy in the peri-operative period. Early postoperative complications (within 30 days) occurred in 16 patients (21.6%) in the PN and four patients in the PCA group. In particular, angioembolization for bleeding was required in the postoperative period in two patients (2.7%) in the PN and one patient in the PCA group. CONCLUSIONS: Our experience suggests that synchronous bilateral PN or PCA are feasible treatment options for select patients presenting with bilateral renal masses. In select cases, both approaches appear to have reasonable rates of peri-operative complications and effects on renal function.

Examining the association between adiposity and biochemical recurrence after radical prostatectomy.

INTRODUCTION: Herein, we examined the association between adiposity, as measured by computed tomography (CT), and biochemical recurrence (BCR) after radical prostatectomy (RP). METHODS: Using axial CT images, preoperative fat mass index (FMI) was calculated for 698 men who underwent RP from 2007-2010 by using measurements of total surface area of adipose tissue at the L3 level. Obesity was classified according to National Health and Nutrition Examination Survey (NHANES) standards for obesity (FMI >9 kg/m2). The associations between obesity and the distribution of adiposity (visceral vs. subcutaneous) with BCR were examined using the Kaplan-Meier method and Cox proportional hazards regression analyses. RESULTS: Obese men were older than non-obese men (63.0 vs. 60.7 years; p<0.001), but were similar with regards to all other clinical and pathological characteristics. With a median followup of six years, 152 patients were diagnosed with BCR. Five-year BCR-free survival was similar between obese and non-obese patients (80.6% vs. 82.1%; p=0.27). Furthermore, in multivariable analyses, obesity was not independently associated with the risk of BCR (hazard ratio [HR] 1.02; 95% confidence interval [CI] 0.73-1.43). Similar results were obtained when analyzing FMI as a continuous variable (HR 1.02; 95% CI 0.94-1.09 for each 1 kg/m2 increase in FMI). Additionally, neither visceral adiposity, subcutaneous adiposity, or visceral-to-subcutaneous adiposity ratio were associated with BCR (all p>0.05) in multivariable analyses. CONCLUSIONS: Neither total abdominal adiposity nor the distribution of adiposity were independently associated with BCR after RP in this study. As such, the presence of obesity may not be a marker of increased oncological risk after RP.

Comparative Survival following Initial Cytoreductive Nephrectomy versus Initial Targeted Therapy for Metastatic Renal Cell Carcinoma.

PURPOSE: The optimal sequence of cytoreductive nephrectomy and targeted therapy of metastatic renal cell carcinoma is unclear. We compared overall survival between patients with metastatic renal cell carcinoma treated with initial cytoreductive nephrectomy with or without subsequent targeted therapy vs initial targeted therapy with or without subsequent cytoreductive nephrectomy. MATERIALS AND METHODS: We evaluated the records of cases in the National Cancer Database diagnosed with metastatic renal cell carcinoma between 2006 and 2013 who were treated with cytoreductive nephrectomy and/or targeted therapy. Receipt of targeted therapy after initial cytoreductive nephrectomy and cytoreductive nephrectomy after initial targeted therapy were evaluated on competing risks analyses. To account for treatment selection bias, inverse probability of treatment weighting was performed based on the propensity to receive initial cytoreductive nephrectomy or initial targeted therapy. Overall survival was compared between the groups by Kaplan-Meier analysis and Cox proportional hazards regression. RESULTS: Of the 15,068 patients included in study 6,731 underwent initial cytoreductive nephrectomy and 8,337 received initial targeted therapy. Six months after initial cytoreductive nephrectomy 48.0% of patients received targeted therapy, of whom 15.3% died after initial cytoreductive nephrectomy prior to targeted therapy. Six months after initial targeted therapy 4.7% of patients underwent cytoreductive nephrectomy, of whom 44.9% died after initial targeted therapy prior to cytoreductive nephrectomy. Initial cytoreductive nephrectomy (OR 2.02, 95% CI 1.69-2.43, p <0.001) and cytoreductive nephrectomy after initial targeted therapy (HR 2.6, 95% CI 1.69-4.01, p <0.001) were more likely to be performed at academic vs community institutions. On inverse probability of treatment weighting analysis initial cytoreductive nephrectomy was associated with improved overall survival compared to initial targeted therapy (median 16.5 vs 9.2 months, HR 0.61, 95% CI 0.59-0.64, p <0.001). CONCLUSIONS: Given the greater likelihood of receiving multimodal therapy and the associated overall survival benefit, these data support cytoreductive nephrectomy as the initial approach to metastatic renal cell carcinoma in appropriate surgical candidates. Continued efforts are warranted to establish the optimal multimodal approach in these patients.

The Association Between Sarcopenia and Oncologic Outcomes After Radical Prostatectomy.

PURPOSE: Sarcopenia is associated with inferior perioperative and oncologic outcomes in patients undergoing surgery for multiple malignancies. The purpose of this study was to evaluate the association between sarcopenia and outcomes after radical prostatectomy (RP) for men with prostate cancer. PATIENTS AND METHODS: Using a representative computed tomographic image from the L3 level, preoperative skeletal muscle indices (SMI) calculated for 698 patients who underwent RP between 2007 and 2010. Patients were classified as sarcopenic if they had a SMI < 55 cm2/kg2 according to international consensus. The associations between sarcopenia and biochemical recurrence (BCR), systemic progression (SP), and all-cause mortality (ACM) were investigated by Cox proportional hazards regression. RESULTS: Sarcopenic patients were older than nonsarcopenic patients (mean age, 63.0 vs. 60.4 years, P < .001) but were otherwise similar with regard to clinical and pathologic characteristics. There was no significant difference in the perioperative complication rate after RP between sarcopenic and nonsarcopenic patients (16.5% vs. 17.4%, P = .82). At a median follow-up after surgery of 6.0 years, 152 patients were diagnosed with BCR, patients were diagnosed with SP, and 50 patients died. In multivariable analysis, the presence of sarcopenia was not significantly associated with the risks of BCR, SP, or ACM. Similar results were obtained when analyzing SMI as a continuous variable. CONCLUSION: Sarcopenia was not found to be independently associated with perioperative complications or oncologic outcomes after RP. As such, the presence of sarcopenia may not be prognostic marker for inferior outcomes among men with localized prostate cancer undergoing RP.