cT1a Renal Masses Less Than 2 versus 2 cm or Greater Managed by Robotic Partial Nephrectomy: A Propensity Score Matched Comparison of Perioperative Outcomes.

PURPOSE: We performed a single center evaluation to compare perioperative, pathological and functional outcomes of robotic partial nephrectomy of T1a renal masses less than vs greater than 2 cm. MATERIALS AND METHODS: Propensity score 1:1 matching of queried patients was performed using the institutional robotic partial nephrectomy database from January 2007 to January 2017. Matching was done by patient age, gender, race, body mass index, the Charlson comorbidity index, smoking status, diabetes, hypertension, hyperlipidemia, ASA® (American Society of Anesthesiologists®) score, estimated glomerular filtration rate, chronic kidney disease stage and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar line and abutting main renal artery or vein) score. We analyzed the records of 524 patients, including 262 with a renal mass less than 2 cm vs 262 with a renal mass 2 cm or greater. Perioperative, pathological and functional outcomes were evaluated. RESULTS: Smaller renal masses (less than 2 cm) were associated with significantly lower operative time, blood loss, ischemia time (mean ± SD 14.3 ± 9.58 vs 21.5 ± 9.51 minutes, p <0.001) and intraoperative transfusions (0% vs 2.7%, p = 0.015). Moreover, we found superior early renal functional outcomes as assessed by the estimated glomerular filtration rate on postoperative day 1 (mean 83.1 ± 21.3 vs 76.6 ± 22.0 mg/ml/1.73 m, p = 0.001), greater parenchymal preservation (mean 89.9% ± 9.45% vs 83.6% ± 8.20%, p <0.001) and a trend toward a lower rate of postoperative complications (13.5% vs 19.5%, p = 0.080). A higher incidence of malignancy was found in larger tumors (85.9% vs 74.8%, p = 0.002) but no difference was recorded in positive surgical margins. CONCLUSIONS: Robotic partial nephrectomy tends to be a low morbidity treatment modality for renal masses less than 2 cm. Although active surveillance is a common option for such tumors, robotic partial nephrectomy remains an alternative in select patients.

Phase II trial of continuous treatment with sunitinib in patients with high-risk (BCG-refractory) non-muscle invasive bladder cancer.

Purpose Sunitinib is a vascular endothelial growth factor receptor (VEGFR) inhibitor with antitumor activity against bladder cancer. We hypothesized that treatment with sunitinib may decrease progression or recurrence in non-muscle invasive bladder cancer (NMIBC) refractory to intra-vesical BCG. Patients and Methods This is a single-arm phase II study of sunitinib in patients (pts) with NMIBC who progressed after BCG. Treatment included sunitinib 37.5 g daily for 12 weeks followed by 12± 2-week cystoscopy and surveillance for one year. The primary endpoint was the complete response rate at 12 months. Secondary endpoints included recurrence free survival (RFS), progression free survival (PFS), overall survival (OS), and safety of sunitinib. Correlative studies on effects of sunitinib on myeloid derived suppressor cells (MDSC) and humoral immune responses were also performed. This trial was registered on ClinicalTrials.gov, number NCT01118351. Results Between June 2011 and September 2011, 15/19 pts. completed 12 weeks of therapy. The remaining 4 pts. had treatment related adverse events leading to discontinuation of sunitinib with one patient withdrawing consent. On the 12-week cystoscopy, 44% (8/18) of the pts. showed remission, 50% (9/18) progression and 1/18 recurrence. Overall, 22% (4/18) of pts. remained free of progression for >12 months. Grade (G) 4 toxicities were noted in 2 pts. (anemia and thrombocytopenia) while G3 were noted in 58%. Sunitinib resulted in reversal of MDSC mediated immunosuppression. Conclusions In NMIBC refractory to BCG, treatment with sunitinib was safe but not associated with improved clinical outcomes. The immune effects of sunitinib deserve further investigation.

When Partial Nephrectomy is Unsuccessful: Understanding the Reasons for Conversion from Robotic Partial to Radical Nephrectomy at a Tertiary Referral Center.

PURPOSE: We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event. MATERIALS AND METHODS: Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion. RESULTS: The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p <0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p <0.01) and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar location) score (9 vs 8, p <0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96-0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22-1.7, p <0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short-term oncologic outcomes but better renal functional preservation (p <0.01). CONCLUSIONS: At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion.

Do Renin-Angiotensin Blockers Affect Renal Function and Cardiac Outcomes in Patients Undergoing Partial Nephrectomy?

PURPOSE: Currently no data exist to guide renal surgeons on the perioperative use of renin-angiotensin blockers despite potential cardiorenal benefits. We aimed to assess the impact of resuming renin-angiotensin blockers on postoperative renal function and adverse cardiac events following partial nephrectomy. MATERIALS AND METHODS: This is an observational analysis of patients who underwent robot-assisted laparoscopic partial nephrectomy from 2006 to 2014 at a single institution. The Wilcoxon rank sum and chi-square tests, and logistic regression were used to assess the risk of adverse renal and cardiac events stratified by history and pattern of renin-angiotensin blockade perioperatively. RESULTS: We identified 900 patients with a median followup of 16.3 months (IQR 1.4-39.1). There were no significant differences in severe renal dysfunction at last followup on univariate analysis or adverse cardiac events at 30 days on multivariate analysis in patients stratified by a history of renin-angiotensin blockade. Of the 338 patients 137 (41.9%) resumed renin-angiotensin blockade immediately after surgery, which did not result in any significant difference in the postoperative glomerular filtration rate (p >0.05). Resuming renin-angiotensin blockade at discharge home was associated with a decreased risk of heart failure within 30 days of surgery (0.3% vs 11.8% of cases) and stage IV/V chronic kidney disease at last followup (2.6% vs 25.5%, each p <0.001). CONCLUSIONS: Renin-angiotensin blockers appear safe to continue immediately after renal surgery. Discharge home with angiotensin converting enzyme inhibitors/angiotensin receptor blockers was associated with a decreased risk of heart failure and severe renal dysfunction. However, this risk may be overstated as a result of the small number of patients discharged without resuming the home medication.

Optimum outcome achievement in partial nephrectomy for T1 renal masses: a contemporary analysis of open and robot-assisted cases.

OBJECTIVES: To compare optimum outcome achievement in open partial nephrectomy (OPN) with that in robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: Using our institutional partial nephrectomy (PN) database, we reviewed 605 cases performed for unifocal clinical T1 renal masses in non-solitary kidneys between 2011 and 2015. Tetrafecta, which was defined as negative surgical margins, freedom from peri-operative complications, ≥80% renal function preservation, and no chronic kidney disease upstaging, was chosen as the composite optimum outcome. Factors associated with tetrafecta achievement were assessed using multivariable logistic regression, with adjustment for age, gender, race, Charlson comorbidity score, body mass index, chronic kidney disease, tumour size, tumour complexity and approach. RESULTS: The overall tetrafecta achievement rate was 38%. Negative margins, freedom from complications, and optimum functional preservation were achieved in 97.1%, 73.6% and 54.2% of cases, respectively. For T1a masses, the tetrafecta achievement rate was similar between approaches (P = 0.97), but for T1b masses, the robot-assisted approach achieved significantly higher tetrafecta rates (43.0% vs 21.3%; P < 0.01). On multivariable analysis, the robot-assisted approach had 2.6-fold higher odds of tetrafecta achievement than the open approach, primarily because of lower peri-operative morbidity, specifically related to wound complications. Positive surgical margin rates and renal function preservation were similar in the two approaches. CONCLUSIONS: Optimum outcomes are readily achieved regardless of PN approach. The robot-assisted approach may facilitate optimum outcome achievement for 4-7-cm masses by minimizing wound complications.

Perioperative epidural analgesia is not associated with increased survival from renal cell cancer, but overall survival may be improved: a retrospective chart review.

PURPOSE: We investigated the possible association between perioperative epidural and both cancer-specific survival (CSS) and overall survival (OS) in patients undergoing partial or radical nephrectomy for localized renal cell carcinoma (RCC). METHODS: A retrospective chart review was performed on patients who underwent complete surgical resection of localized RCC from 1994-2008 at our institution. Baseline demographics and pathological and survival data were collected. Patients with clinically or pathologically positive lymph nodes or metastatic disease at the time of surgery were excluded. Patients with pathologically positive surgical margins were also excluded. Patients were divided into two groups, systemic analgesia and epidural analgesia. Multivariable Cox regression analysis was used to determine CSS and OS, and survival curves were generated using the Kaplan-Meier method. RESULTS: Four hundred thirty-eight patients were included in the analysis. Baseline characteristics of both groups were similar. Median follow-up was 77 months. On multivariable analysis, patient age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.02 to 1.07), epidural status (HR, 0.5; 95% CI, 0.4 to 0.8), year of surgery (HR, 0.9; 95% CI, 0.89 to 0.95), and pathologic T-stage (pT-stage) ≥ 2 (pT-stage2: HR, 2.2; 95% CI, 1.2 to 4.1 and pT-stage3: HR, 3.1; 95% CI, 2.0 to 4.7) were independent predictors of OS. Nevertheless, epidural status did not significantly predict CSS (P = 0.73), while T-stage and year of surgery maintained their respective predictive significance. Tumour grade did not significantly affect OS or CSS. CONCLUSIONS: Our retrospective analysis suggests that epidural at the time of surgical excision of localized RCC does not significantly impact CSS. Nevertheless, use of epidural was associated with significantly improved OS. Future prospective clinical and laboratory studies are warranted in order to characterize these associations further and determine the underlying mechanisms.

Surgical Salvage of Thermal Ablation Failures for Renal Cell Carcinoma.

PURPOSE: Cryoablation and radio frequency ablation are attractive modalities for small renal masses in patients with substantial comorbidities. However, salvage extirpative therapy for local recurrence after thermal ablation can be challenging due to associated perinephric fibrosis. MATERIALS AND METHODS: Patients with thermal ablation refractory tumors requiring surgical salvage from 1997 to 2013 were identified and retrospectively reviewed. RESULTS: A total of 27 patients were treated surgically after cryoablation (18) or radio frequency ablation (9) failed. Subjective assessment indicated moderate/severe fibrosis in 22 cases (81%). Partial nephrectomy was preferred in all patients but was not possible in 12, primarily due to unfavorable tumor size/location. In the intended partial nephrectomy group (15) open surgery was performed in all patients and completed in 14, with the procedure aborted in 1 due to extensive perinephric fibrosis. Radical nephrectomy was planned in 12 patients, of whom 8 were treated laparoscopically with 1 requiring conversion to open. Median estimated blood loss was 225 ml. Overall 17 patients experienced no complications and 4 had minor complications. However, 6 patients experienced more significant complications (Clavien III-IVb). Since January 2008 partial nephrectomy was performed more frequently (12 of 17, or 71% vs 2 of 10, or 20% for previous cases, p=0.02). CONCLUSIONS: Surgical salvage after failed thermal ablation is feasible in most instances, and partial nephrectomy is often possible but can be challenging due to associated perinephric fibrosis. The difficulty of surgical salvage should be recognized as a potential limitation of the thermal ablation treatment strategy. Prospective studies of thermal ablation vs partial nephrectomy should be prioritized to provide higher quality data about the merits and limitations of each approach.

A Phase II Study of Pazopanib in Patients with Localized Renal Cell Carcinoma to Optimize Preservation of Renal Parenchyma.

PURPOSE: Preservation of renal function is prioritized during surgical management of localized renal cell carcinoma. VEGF targeted agents can downsize tumors in metastatic renal cell carcinoma and may do the same in localized renal cell carcinoma, allowing for optimal preservation of renal parenchyma associated with partial nephrectomy. MATERIALS AND METHODS: Localized clear cell renal cell carcinoma patients meeting 1 or both of the following criteria were enrolled in a prospective phase II trial, including radical or partial nephrectomy likely to yield a glomerular filtration rate of less than 30 ml/minute/1.73 m(2), or partial nephrectomy high risk due to high complexity (R.E.N.A.L. 10 to 12) or tumor adjacent to hilar vessels. Pazopanib (800 mg once daily) was administered for 8 to 16 weeks with repeat imaging at completion of therapy, followed by surgery. RESULTS: A total of 25 patients enrolled with a median tumor size of 7.3 cm and a median R.E.N.A.L. score of 11. Of index lesions 80% were high complexity and 56% of patients had a solitary kidney. Patients received a median of 8 weeks of pazopanib. The median interval from treatment start to surgery was 10.6 weeks. R.E.N.A.L. score decreased in 71% of tumors and 92% of patients experienced a reduction in tumor volume. Six of 13 patients for whom partial nephrectomy was not possible at baseline were able to undergo partial nephrectomy after treatment. The mean parenchymal volume that could be saved with surgery increased from an estimated 107 to 173 cc (p = 0.0015). In 5 patients a urine leak developed, which was managed conservatively, and 7 received a transfusion, of whom 1 required embolization. CONCLUSIONS: Neoadjuvant pazopanib resulted in downsizing localized renal cell carcinoma, allowing for improved preservation of renal parenchyma and enabling partial nephrectomy in a select subset of patients who would otherwise require radical nephrectomy.

Chronic kidney disease due to surgical removal of nephrons: relative rates of progression and survival.

PURPOSE: Chronic kidney disease is associated with a higher likelihood of progression to end stage renal disease and increased mortality rates. However, the etiology of nephron loss may modify the rate of chronic kidney disease progression and overall survival. MATERIALS AND METHODS: Patients with suspected renal malignancy who had a new baseline glomerular filtration rate of less than 60 ml/minute/1.73 m(2) 6 weeks after surgery were divided into the 2 groups of surgically induced chronic kidney disease (preoperative glomerular filtration rate greater than 60 ml/minute/1.73 m(2)) and preexisting chronic kidney disease due to medical causes followed by surgery. An independent cohort of subjects with chronic kidney disease entirely due to medical causes served as a comparator. RESULTS: Renal cancer surgery yielded cohorts with surgically induced chronic kidney disease (1,097) and chronic kidney disease due to medical causes followed by surgery (1,053), whereas the group with chronic kidney disease due to medical causes consisted of 42,658 subjects. The patients with chronic kidney disease due to medical causes and chronic kidney disease from medical causes followed by surgery were older compared to those with surgically induced chronic kidney disease, had more medical comorbidities and had a lower baseline glomerular filtration rate (all p <0.001). The group with chronic kidney disease due to medical causes followed by surgery had a lower mean (±SD) new baseline glomerular filtration rate (37±10) compared to the surgically induced chronic kidney disease (48±9) and chronic kidney disease due to medical comorbidities (47±10) groups (p <0.001). The probability of progressive decline in renal function (50% decrease in glomerular filtration rate or need for dialysis) at 3 years was lowest for surgically induced chronic kidney disease, intermediate for chronic kidney disease from medical causes followed by surgery and highest for chronic kidney disease from medical causes when age, gender, race, comorbidities and new baseline glomerular filtration rate were considered (p <0.001). Nonrenal cancer related mortality was substantially lower for those with surgically induced chronic kidney disease compared to the other groups (p <0.001). CONCLUSIONS: Our data suggest that surgically induced chronic kidney disease has a lower rate of functional decline and less impact on survival than chronic kidney disease due to medical causes. These data have potential implications with respect to chronic kidney disease classification and patient counseling for surgical management of various renal disorders including renal cancer.

Alvimopan, a peripherally acting µ-opioid receptor antagonist, is associated with reduced costs after radical cystectomy: economic analysis of a phase 4 randomized, controlled trial.

PURPOSE: We evaluated the effect of alvimopan treatment vs placebo on health care utilization and costs related to gastrointestinal recovery in patients treated with radical cystectomy in a randomized, phase 4 clinical trial. MATERIALS AND METHODS: Resource utilization data were prospectively collected and evaluated by cost consequence analysis. Hospital costs were estimated from 2012 Medicare reimbursement rates and medication wholesale acquisition costs. Differences in base case mean costs between the study cohorts for total postoperative ileus related costs (hospital days, study drug, nasogastric tubes, postoperative ileus related concomitant medication and postoperative ileus related readmissions) and total combined costs (postoperative ileus related, laboratory, electrocardiograms, nonpostoperative ileus related concomitant medication and nonpostoperative ileus related readmission) were evaluated by probabilistic sensitivity analysis using a bootstrap approach. RESULTS: Mean hospital stay was 2.63 days shorter for alvimopan than placebo (mean±SD 8.44±3.05 vs 11.07±8.23 days, p=0.005). Use of medications or interventions likely intended to diagnose or manage postoperative ileus was lower for alvimopan than for placebo, eg total parenteral nutrition 10% vs 25% (p=0.001). Postoperative ileus related health care costs were $2,340 lower for alvimopan and mean total combined costs were decreased by $2,640 per patient for alvimopan vs placebo. Analysis using a 10,000-iteration bootstrap approach showed that the mean difference in postoperative ileus related costs (p=0.04) but not total combined costs (p=0.068) was significantly lower for alvimopan than for placebo. CONCLUSIONS: In patients treated with radical cystectomy alvimopan decreased hospitalization cost by reducing the health care services associated with postoperative ileus and decreasing the hospital stay.

Biochemical and radiological relationships in patients with pheochromocytoma: lessons from a case control study.

BACKGROUND: An elevation of fractionated plasma or urinary metanephrine (MN) or nor-metanephrine (NMN), collectively called metanephrines (MN and NMN), >4-fold above the upper limit of normal (ULN) is usually considered to be diagnostic for pheochromocytoma (PHEO). There are a greater number of false positive results when the elevations are more modest. AIM: To identify biochemical and radiological features in PHEOs with modest elevations (<4-fold above ULN) of metanephrines. METHODOLOGY: We retrospectively reviewed the charts of 112 patients with PHEO (10% extra-adrenal) and 208 patients with a non-PHEO adrenal mass operated from 1997-2011, who had metanephrines measured pre-operatively. We divided PHEO into group 1 (n = 90) with metanephrines ≥4-fold ULN and group 2 (n = 22) with metanephrines <4-fold ULN. The non-PHEO group was designated as group 3. RESULTS: The median (range) tumour size in group 1 and group 2 was 4·8 cm (1·7-22) and 3·0 cm (1·7-5) respectively (P < 0·001). All patients with PHEO in group 2 had a tumour <5 cm in size. The MN fraction was elevated in about 65% of groups 1 and 2; only 2 (1%) patients in group 3 had an elevated urinary MN fraction, and none were associated with an elevated plasma MN fraction. All PHEOs had a pre-contrast attenuation ≥17 Hounsfield Units (HU). CONCLUSIONS: Modest elevations (<4-fold ULN) of the NMN fraction in an adrenal mass >5 cm are almost always falsely positive. Elevations in plasma and urinary MN fraction are less likely to be false positive. The CT pre-contrast attenuation of PHEOs is >10 HU.

Is all chronic kidney disease created equal?

PURPOSE OF REVIEW: Chronic kidney disease (CKD) has generally been characterized functionally as a glomerular filtration rate (GFR) less than 60 ml/min/1.73 m², without accounting for cause, signs of structural damage, or relative risk of sequelae. Recently released guidelines define CKD as abnormalities of kidney structure or function, present for more than 3 months. We review the recent literature about CKD and its implications for renal surgery. RECENT FINDINGS: Most estimates of GFR are based on serum creatinine, after adjusting for age, race, sex, and/or body mass. Recent research indicates that many individuals have GFR values less than 60 ml/min/1.73 m² without other manifestations of CKD. Nephron loss due to normal aging or renal surgery (CKD-S) may have lower likelihood of CKD progression, and may infer better survival, compared to individuals with the same degree of CKD due to medical causes. Patients with mild and moderate CKD due to surgical nephron loss may benefit from an alternative measurement method of renal function such as cystatin-C-derived or directly measured GFR. SUMMARY: CKD includes a diverse group of individuals with reduced GFR from a variety of causes. Classification of CKD according to GFR, albuminuria, and cause, may improve the management of patients with reduced GFR, as some causes (e.g., nephrectomy and aging) appear to be associated with a relatively low risk of progression.

Long-Term Functional and Oncologic Outcomes Following Robotic Partial and Radical Nephrectomy: A Report from a Single Institution with up to 15 Years of Follow-Up.

Objective: To evaluate the long-term functional and oncologic outcomes after robotic partial nephrectomy (RAPN) and radical nephrectomy (RARN). Materials and Methods: A retrospective review was performed on 1816 patients who underwent RAPN and RARN at our institution between January 2006 and January 2018. Patients with long-term follow-ups of at least 5 years were selected. Exclusion criteria included patients with a previous history of partial or radical nephrectomy, known genetic mutations, and whose procedures were performed for benign indications. Statistical analysis was performed with results as presented. Results: A total of 769 and 142 patients who underwent RAPN and RARN, respectively, met our inclusion criteria. The duration of follow-up was similar after the two procedures with a median of ∼100 months. The 5- and 10-year chronic kidney disease (CKD) upstaging-free survivals were 74.5% and 65.9% after RAPN and 53% and 46.4% after RARN, respectively. Older age was identified as a potential predictor for CKD progression after RARN, whereas older age, higher body mass index, baseline renal function, and ischemia time were shown to predict CKD progression after RAPN. Renal cell carcinoma-related mortality rates for RAPN and RARN were equally 1.1%. No statistically significant differences were identified in the local recurrence, metastatic, and disease-specific survival between the two procedures. Conclusion: Compared with RARN, RAPN conferred a better CKD progression-free survival. Several factors were identified as potential predictors for clinically significant CKD progression both in the early and late postoperative phase. Long-term oncologic outcomes between the two procedures remained similarly favorable.

Surgically induced chronic kidney disease may be associated with a lower risk of progression and mortality than medical chronic kidney disease.

PURPOSE: Chronic kidney disease from medical causes is present in 25% to 30% of patients before surgery for renal cancer. Although chronic kidney disease due to medical causes is typically associated with a 2% to 5% annual renal functional decline and decreased overall survival, reduced glomerular filtration rate occurring only after surgery may not have the same negative consequences. MATERIALS AND METHODS: All patients undergoing surgery for suspected renal malignancy were identified in an institutional registry. Median clinical followup was 6.6 years. RESULTS: Of 4,180 patients 28% had a preoperative glomerular filtration rate of less than 60 ml/minute/1.73 m(2) (chronic kidney disease due to medical causes) and in 22% the glomerular filtration rate decreased to less than 60 ml/minute/1.73 m(2) only after surgery (surgically induced chronic kidney disease). Preoperative glomerular filtration rate was a strong predictor of overall survival on univariable and multivariable analysis. The risk of death after renal surgery was 1.8, 3.5 and 4.4-fold higher in patients with preoperative chronic kidney disease stages 3, 4 and 5, respectively, vs normal preoperative glomerular filtration rate. Average overall loss of renal function was 23%, including 13% within 90 days after surgery and 3.5% annually thereafter. Postoperative glomerular filtration rate only predicted survival for patients with preexisting chronic kidney disease due to medical causes. Neither surgically induced chronic kidney disease nor postoperative glomerular filtration rate was a significant predictor of survival in patients without preexisting chronic kidney disease due to medical causes. Annual renal functional decline was 4.7% and 0.7% for patients with chronic kidney disease due to medical causes and surgically induced chronic kidney disease, respectively, with a greater than 50% reduction in glomerular filtration rate in 7.3% and 2.2%, respectively (p <0.0001). Annual renal functional decline greater than 4.0% was associated with a 43% increase in mortality (p <0.0001). CONCLUSIONS: Surgically induced chronic kidney disease is associated with a relatively low risk of progressive renal functional decline and impact on survival does not appear to be substantial during intermediate term followup. In contrast, preoperative chronic kidney disease due to medical causes places patients at increased risk, indicating nephron sparing surgery for such patients.

The sensitivity of initial transurethral resection or biopsy of bladder tumor(s) for detecting bladder cancer variants on radical cystectomy.

PURPOSE: We determined the ability of bladder biopsy and transurethral resection of the bladder to accurately predict bladder cancer variants on radical cystectomy since certain variants may affect prognosis and treatment. MATERIALS AND METHODS: We retrospectively evaluated the records of 302 patients who underwent biopsy and/or transurethral resection of the bladder followed by radical cystectomy from 2008 to 2010. The frequency of variant morphology and the sensitivity of the precystectomy material was determined using pathological findings at radical cystectomy as the final result. RESULTS: Bladder cancer variants were identified in 159 patients (53%) on initial biopsy/transurethral resection and/or final pathological evaluation at radical cystectomy. The most common variant was urothelial carcinoma with squamous differentiation in 72 of 159 patients (45%), followed by micropapillary urothelial carcinoma in 41 (26%). In 9 patients (6%) variant morphology was identified only on biopsy/transurethral resection bladder and not on final radical cystectomy pathological assessment. The remaining 150 patients (94%) showed variant morphology on radical cystectomy with (79 or 53%) or without (71 or 47%) variant morphology on the preceding biopsy/transurethral resection. The sensitivity of variant detection showed a broad range by variant subtype. Overall, initial biopsy/transurethral resection sensitivity was 39% for predicting variant morphology on radical cystectomy. CONCLUSIONS: Overall sensitivity for predicting bladder cancer variants from biopsy/transurethral resection of the bladder sampling is relatively low. This is likely due to sampling and tumor heterogeneity rather than to an inaccurate pathological diagnosis. Additional predictive markers of variant morphology may be useful to determine which tumors contain aggressive variants that may alter outcomes or therapy.

Association between warm ischemia time and renal parenchymal atrophy after partial nephrectomy.

PURPOSE: Renal parenchymal volume decrease after partial nephrectomy is associated with late functional outcomes. We examined the relative effects of resection related and atrophy related volume change on late kidney function. MATERIALS AND METHODS: Data were analyzed from a cohort of 187 patients who underwent open, laparoscopic or robotic partial nephrectomy between 2009 and 2011. Total change in kidney size after surgery was expressed as percent functional volume preservation measured using the cylindrical volume ratio method. Renal atrophy was expressed as parenchymal thickness preservation, and was assessed by measuring parenchymal thickness before and after partial nephrectomy in regions of the operated kidney distant from the site of resection. Standard statistical analyses were conducted to assess relationships among variables. RESULTS: Mean (± SD) percent functional volume preservation was 92% (± 8%), which correlated with a late percent glomerular filtration rate preservation of 91% (± 12%). Mean parenchymal thickness preservation for the cohort was 99% (± 4%). Minimal atrophy was observed in patients with warm ischemia time less than 40 minutes (parenchymal thickness preservation range 98% to 100%). Atrophy was more pronounced in patients with warm ischemia time greater than 40 minutes (parenchymal thickness preservation 96%). Multivariate regression analysis showed correlation of percent functional volume preservation with atrophy; correlation of warm ischemia time, diameter-axial-polar nephrometry score and atrophy with percent functional volume preservation; and correlation of Charlson score and diameter-axial-polar nephrometry score with percent decrease in glomerular filtration rate. CONCLUSIONS: In most patients with warm ischemia time less than 40 minutes the incidence of parenchymal atrophy was minimal, suggesting that the kidney volume decrease after partial nephrectomy was predominantly resection related. Kidney volume decrease after partial nephrectomy in patients with warm ischemia time greater than 40 minutes appeared to be due to a combination of resection related and atrophy related changes.

Five to 10-year followup of open partial nephrectomy in a solitary kidney.

PURPOSE: Followup is limited in patients with a solitary kidney who undergo partial nephrectomy. We evaluated overall, cancer specific and recurrence-free survival, and renal function in patients 5 years or greater after open partial nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the Cleveland Clinic kidney cancer database, including only patients with a solitary kidney treated with open partial nephrectomy 5 or more years ago (from 1980 to June 2006) who had 6 months or more of followup. Survival and recurrence analyses were calculated using a Cox proportional hazards model. Results are shown as Kaplan-Meier survival curves. Linear regression analysis was done to assess postoperative renal function. RESULTS: A total of 282 patients fit our study inclusion criteria (mean followup 175 months), of whom 233 underwent open partial nephrectomy 10 or more years ago. Actual overall survival was 78.5% and 59.5% at 5 and 10 years, respectively. The average estimated glomerular filtration rate at 5 years or greater and 10 years or greater since open partial nephrectomy was 35.1 and 34.5 ml/minute/1.73 m(2) in 89.7% and 89.6%, respectively, of patients with stage 3 or greater chronic kidney disease. Eight survivors were on intermittent hemodialysis 5 years or more postoperatively, including 5 at 10 years or more. There were 76 recurrences for a calculated 5 and 10-year recurrence-free survival rate of 72% (95% CI 66-879) and 63% (95% CI 57-71), respectively. CONCLUSIONS: Open partial nephrectomy in the solitary kidney provides reliable long-term oncological control at 5 and 10 years. Predicted and actual outcomes correspond well. Although most patients have chronic kidney disease postoperatively, it appears stable with minimal progression to dialysis.

Comparative outcomes of laparoscopic and open adrenalectomy for adrenocortical carcinoma: single, high-volume center experience.

PURPOSE: Adrenocortical carcinoma (ACC) is a rare and clinically aggressive cancer. Previous studies reported increased recurrence rates associated with laparoscopic adrenalectomy (LA). We evaluated a single-center experience of LA versus open adrenalectomy (OA) for the management of ACC. METHODS: Between 1993 and 2011, 44 consecutive patients with primary ACC were treated at our institution. Baseline patient characteristics and surgical and pathological outcomes were compared between OA and LA groups. Multivariable Cox proportional hazards analysis was used to estimate the association between OA versus LA with recurrence-free and overall survival. RESULTS: Eighteen and 26 patients underwent LA and OA, respectively. Patients who underwent OA had larger tumors and more advanced clinical stage compared with LA group. During a median follow-up of 22 months, 22 recurrences and 26 deaths were observed. The 2-year, recurrence-free and overall survivals for OA and LA were 60 vs. 39 % (P = 0.7) and 54 vs. 58 % (P = 0.6), respectively. After adjusting for clinical stage, OA was associated with lower risk of recurrence (hazard ratio (HR) 0.4; 95 % confidence interval (CI) 0.2-1.2; P = 0.099) and improved overall survival (HR 0.5; 95 % CI 0.2-1.2; P = 0.122) compared with LA, although differences were not statistically significant. CONCLUSIONS: A nonstatistically significant increase in recurrence and death was observed among patients undergoing LA versus OA after adjusting for clinical stage. The rarity of this disease limits the ability to assess for significant differences in a single-institution series. Patients with suspected ACC should be considered for OA.

Chronic renal insufficiency after partial nephrectomy for T1b tumors.

PURPOSE OF REVIEW: Partial nephrectomy for larger kidney tumors (T1b) has gained widespread acceptance in most academic institutions, with similar oncologic outcomes to radical nephrectomy. This review focuses on the factors that affect renal function after partial nephrectomy, and presents current information about the relative importance of each factor as well as chronic kidney disease (CKD) after renal surgery. RECENT FINDINGS: CKD occurs over the long term in a significant percentage of patients following partial nephrectomy. The interaction of different factors including baseline kidney function (influenced by age and medical comorbidity), amount of preserved renal parenchyma (influenced by surgical technique), and ischemia time (warm or cold) determines the ultimate functional outcome. De-novo CKD resulting from surgery in previously healthy individuals may not place these patients at increased risk of progression or mortality. SUMMARY: Urologists continue to strive towards improved kidney function after partial nephrectomy, particularly for larger tumors. Careful identification of factors involved in functional outcome, and optimization of modifiable factors, will remain at the forefront of efforts to minimize renal functional loss after partial nephrectomy.

Functional recovery after partial nephrectomy: effects of volume loss and ischemic injury.

PURPOSE: We used what is to our knowledge a new method to estimate volume loss after partial nephrectomy to assess the relative contributions of ischemic injury and volume loss on functional outcomes. MATERIALS AND METHODS: We analyzed the records of 301 consecutive patients who underwent conventional partial nephrectomy between 2007 and 2010 with available data to meet inclusion criteria. Percent functional volume preservation was measured at a median of 1.4 years after surgery. Modification of diet in renal disease-2 estimated glomerular filtration rate was measured preoperatively and perioperatively, and a median of 1.2 years postoperatively. Statistical analysis was done to study associations. RESULTS: Hypothermia or warm ischemia 25 minutes or less was applied in 75% of cases. Median percent functional volume preservation was 91% (range 38%-107%). Percent glomerular filtration rate preservation at nadir and late time points was 77% and 90% of preoperative glomerular filtration rate, respectively. On multivariate analysis percent functional volume preservation and warm ischemia time were associated with nadir glomerular filtration rate while only percent functional volume preservation was associated with late glomerular filtration rate (each p <0.001). Late percent glomerular filtration rate preservation and percent functional volume preservation were directly associated (p <0.001). Recovery of function to 90% or greater of percent functional volume preservation predicted levels was observed in 86% of patients. In patients with de novo postoperative stage 3 or greater chronic kidney disease, percent functional volume preservation and Charlson score were associated with late percent glomerular filtration rate preservation. Warm ischemia time was not associated with late functional glomerular filtration rate decreases in patients considered high risk for ischemic injury. CONCLUSIONS: In this cohort volume loss and not ischemia time was the primary determinant of ultimate renal function after partial nephrectomy. Technical modifications aimed at minimizing volume loss during partial nephrectomy while still achieving negative margins may result in improved functional outcomes.