Renal cell carcinoma, clear cell type with secondary polycythemia in a young Filipino male: A case report

Introduction@#Clear Cell Renal Cell Carcinoma, a renal cortical tumor characterized by malignant epithelial cells with clear cytoplasm and compact alveolar or acinar growth pattern interspersed with intricate arborizing vasculature.1 This is rare in people less than 45 years old. Though it has varied clinical manifestations, its classical triad: abdominal mass, hematuria, and groin pain only present in four to 17% of cases.2 We therefore present a case of renal cell carcinoma occurring in an unusual age group who presented with vague gastrointestinal symptoms and polycythemia which accounts only less than 5% of cases.3@*Case Presentation@#This is a case of a 28-year-old Filipino male who presented with epigastric pain with abdominal fullness and anorexia who later complained of frequent vomiting after solid and liquid intake. CBC revealed polycythemia. Gastroscopy with biopsy showed esophagitis Los Angeles classification Grade A and duodenal mass obstructing 95% of the lumen. Computed tomographic scan of whole abdomen revealed large renal mass, right of 15.9x9.35x11.34cm extending superiorly at the antropyloric region causing gastric luminal narrowing down to first and second segments of duodenum with a 4.2cm enlarged lymph node in aortocaval area. Magnetic resonance imaging revealed a huge complex right renal mass of 12x12x10cm in size extending beyond Gerota’s fascia with 8x5.2x6.2cm lymph node compressing the vena cava. Right radical nephrectomy was done for both supportive management to relieve the obstruction and for histologic diagnosis which revealed clear cell renal cell carcinoma. JAK2 gene mutation test was done to determine the cause of polycythemia and phlebotomy was performed to address the problem.@*Conclusion@#This case presents with vague gastrointestinal symptoms which is atypical of renal cell carcinoma, hence highlights the importance of properly investigating its cause. Furthermore, a multidisciplinary approach involving different subspecialties plays a significant role in the diagnosis and management in this patient.

Survival analysis and predictors of long-term outcomes following radical nephrectomy with inferior vena cava (IVC) thrombectomy in renal cell carcinoma

Background: Renal cell carcinoma (RCC) presents with inferior vena cava (IVC) thrombus in 10%�% cases and surgical management forms the mainstay of the treatment. The objective of this study is to assess the outcomes of the patients undergoing radical nephrectomy with IVC thrombectomy. Methods: A retrospective analysis of patients undergoing open radical nephrectomy with IVC thrombectomy between 2006 till 2018 was done. Results: A total of 56 patients were included. The mean (眘tandard deviation) age was 57.1 (�.2) years. The number of patients with levels I, II, III, and IV thrombus were 4, 29,10, and 13, respectively. The mean blood loss was 1851.8 mL, and the mean operative time was 303.3 minutes. Overall, the complication rate was 51.7%, while the perioperative mortality rate was 8.9%. The mean duration of hospital stay was 10.6 � 6.4 days. The majority of the patients had clear cell carcinoma (87.5%). There was a significant association between grade and stage of thrombus (P = 0.011). Using Kaplan朚eier survival analysis, the median overall survival (OS) was 75 (95% confidence interval [CI] = 43.5�6.5) months, and the median recurrence-free survival (RFS) was 48 (95% CI = 33.1�.3) months. Age (P = 0.03), presence of systemic symptoms (P = 0.01), radiological size (P = 0.04), histopathological grade (P = 0.01), level of thrombus (P = 0.04), and invasion of thrombus into IVC wall (P = 0.01) were found to be significant predictors of OS. Conclusion: The management of RCC with IVC thrombus poses a major surgical challenge. Experience of a center along with high-volume and multidisciplinary facility particularly cardiothoracic facility provides better perioperative outcome. Though surgically challenging, it offers good overall-survival and recurrence-free survival

Application of laparoscopic ultrasound in retroperitoneal radical nephrectomy for renal cell carcinoma with Type II inferior vena cava tumor thrombectomy

Background: The aim of this study was to investigate the application value of laparoscopic ultrasound (LU) in retroperitoneal radical nephrectomy for renal cell carcinoma with Type II inferior vena cava tumor thrombectomy (RRN-RCC-TII-IVCTT). Methods: The clinical data (operative time, length of tumor thrombus, tumor length, intraoperative bleeding, clinical stage, histological type, residual tumor tissue, and postoperative follow-up) of 6 patients who underwent LU-guided RRN-RCC-TII-IVCTT were retrospectively analyzed, and the intraoperative experience of LU was also summarized. Results: All 6 patients recovered well with liver and kidney functions returning to normal, and no tumor recurrence, metastasis, or vena cava tumor thrombus. Conclusions: LU-guided RRN-RCC-TII-IVCTT is a feasible treatment option, which locates the tumor accurately by retroperitoneal approach and provides the additional benefit of reduced intraoperative bleeding and shortened operative time, also achieving the much sought-after goal of precision.

Establishment and validation of a novel nomogram to predict overall survival after radical nephrectomy / 中华肿瘤杂志

Objective: To establish a nomogram prognostic model for predicting the 5-, 10-, and 15-year overall survival (OS) of non-metastatic renal cell carcinoma patients managed with radical nephrectomy (RN), compare the modelled results with the results of pure pathologic staging, the Karakiewicz nomogram and the Mayo Clinic Stage, Size, Grade, and Necrosis (SSIGN) score commonly used in foreign countries, and stratify the patients into different prognostic risk subgroups. Methods: A total of 1 246 non-metastatic renal cell carcinoma patients managed with RN in Sun Yat-sen University Cancer Center (SYSUCC) from 1999 to 2020 were retrospectively analyzed. Multivariate Cox regression analysis was used to screen the variables that influence the prognosis for nomogram establishment, and the bootstrap random sampling was used for internal validation. The time-receiver operating characteristic curve (ROC), the calibration curve and the clinical decision curve analysis (DCA) were applied to evaluate the nomogram. The prediction efficacy of the nomogram and that of the pure pathologic staging, the Karakiewicz nomogram and the SSIGN score was compared through the area under the curve (AUC). Finally, patients were stratified into different risk subgroups according to our nomogram scores. Results: A total of 1 246 patients managed with RN were enrolled in this study. Multivariate Cox regression analysis showed that age, smoking history, pathological nuclear grade, sarcomatoid differentiation, tumor necrosis and pathological T and N stages were independent prognostic factors for RN patients (all P<0.05). A nomogram model named SYSUCC based on these factors was built to predict the 5-, 10-, and 15-year survival rate of the participating patients. In the bootstrap random sampling with 1 000 iterations, all these factors occurred for more than 800 times as independent predictors. The Harrell's concordance index (C-index) of SYSUCC was higher compared with pure pathological staging [0.770 (95% CI: 0.716-0.823) vs 0.674 (95% CI: 0.621-0.728)]. The calibration curve showed that the survival rate as predicted by the SYSUCC model simulated the actual rate, while the clinical DCA showed that the SYSUCC nomogram has a benefit in certain probability ranges. In the ROC analysis that included 857 patients with detailed pathological nuclear stages, the nomogram had a larger AUC (5-/10-year AUC: 0.823/0.804) and better discriminating ability than pure pathological staging (5-/10-year AUC: 0.701/0.658), Karakiewicz nomogram (5-/10-year AUC: 0.772/0.734) and SSIGN score (5-/10-year AUC: 0.792/0.750) in predicting the 5-/10-year OS of RN patients (all P<0.05). In addition, the AUC of the SYSUCC nomogram for predicting the 15-year OS (0.820) was larger than that of the SSIGN score (0.709), and there was no statistical difference (P<0.05) between the SYSUCC nomogram, pure pathological staging (0.773) and the Karakiewicz nomogram (0.826). The calibration curve was close to the standard curve, which indicated that the model has good predictive performance. Finally, patients were stratified into low-, intermediate-, and high-risk subgroups (738, 379 and 129, respectively) according to the SYSUCC nomogram scores, among whom patients in intermediate- and high-risk subgroups had a worse OS than patients in the low-risk subgroup (intermediate-risk group vs. low-risk group: HR=4.33, 95% CI: 3.22-5.81, P<0.001; high-risk group vs low-risk group: HR=11.95, 95% CI: 8.29-17.24, P<0.001), and the high-risk subgroup had a worse OS than the intermediate-risk group (HR=2.63, 95% CI: 1.88-3.68, P<0.001). Conclusions: Age, smoking history, pathological nuclear grade, sarcomatoid differentiation, tumor necrosis and pathological stage were independent prognostic factors for non-metastasis renal cell carcinoma patients after RN. The SYSUCC nomogram based on these independent prognostic factors can better predict the 5-, 10-, and 15-year OS than pure pathological staging, the Karakiewicz nomogram and the SSIGN score of patients after RN. In addition, the SYSUCC nomogram has good discrimination, agreement, risk stratification and clinical application potential.

Long-term survival analysis of 1 367 patients treated with radical nephrectomy from a single center / 中华肿瘤杂志

Objective: To report the long-term survival of renal cell carcinoma (RCC) patients treated with radical nephrectomy in Sun Yat-sen University Cancer Center. Methods: We retrospectively analyzed the clinical, pathological and follow-up records of 1 367 non-metastatic RCC patients treated with radical nephrectomy from 1999 to 2020 in this center. The primary endpoint of this study was overall survival rate. Survival curves were estimated using the Kaplan-Meier method, and group differences were compared through Log-rank test. Univariate and multivariate Cox analysis were fit to determine the clinical and pathological features associated with overall survival rate. Results: A total of 1 367 patients treated with radical nephrectomy with complete follow-up data were included in the study. The median follow-up time was 52.6 months, and 1 100 patients survived and 267 died, with the median time to overall survival not yet reached. The 5-year and 10-year overall survival rates were 82.8% and 74.9%, respectively. The 5-year and 10-year overall survival rates of Leibovich low-risk patients were 93.3% and 88.2%, respectively; of Leibovich intermediate-risk patients were 82.2% and 72.3%, respectively; and of Leibovich high-risk patients were 50.5% and 30.2%, respectively. There were significant differences in the long-term survival among the three groups (P<0.001). The 10-year overall survival rates for patients with pT1, pT2, pT3 and pT4 RCC were 83.2%, 73.6%, 55.0% and 31.4%, respectively. There were significant differences among pT1, pT2, pT3 and pT4 patients(P<0.001). The 5-year and 10-year overall survival rates of patients with lymph node metastasis were 48.5% and 35.6%, respectively, and those of patients without lymph node metastasis were 85.1% and 77.5%, respectively. There was significant difference in the long-term survival between patients with lymph node metastasis and without lymph node metastasis. The 10-year overall survival rate was 96.2% for nuclear Grade 1, 81.6% for nuclear Grade 2, 60.5% for nuclear Grade 3, and 43.4% for nuclear Grade 4 patients. The difference was statistically significant. There was no significant difference in the long-term survival between patients with localized renal cancer (pT1-2N0M0) who underwent open surgery and minimally invasive surgery (10-year overall survival rate 80.5% vs 85.6%, P=0.160). Multivariate Cox analysis showed that age≥55 years (HR=2.11, 95% CI: 1.50-2.96, P<0.001), T stage(T3+ T4 vs T1a: HR=2.37, 95% CI: 1.26-4.46, P=0.008), local lymph node metastasis (HR=3.04, 95%CI: 1.81-5.09, P<0.001), nuclear grade (G3-G4 vs G1: HR=4.21, 95%CI: 1.51-11.75, P=0.006), tumor necrosis (HR=1.66, 95% CI: 1.17-2.37, P=0.005), sarcomatoid differentiation (HR=2.39, 95% CI: 1.31-4.35, P=0.005) and BMI≥24kg/m(2) (HR=0.56, 95%CI: 0.39-0.80, P=0.001) were independent factors affecting long-term survival after radical nephrectomy. Conclusions: The long-term survival of radical nephrectomy in patients with renal cell carcinoma is satisfactory. Advanced age, higher pathological stage and grade, tumor necrosis and sarcomatoid differentiation were the main adverse factors affecting the prognosis of patients. Higher body mass index was a protective factor for the prognosis of patients.

Establishment and validation of a novel nomogram to predict overall survival after radical nephrectomy / 中华肿瘤杂志

Objective: To establish a nomogram prognostic model for predicting the 5-, 10-, and 15-year overall survival (OS) of non-metastatic renal cell carcinoma patients managed with radical nephrectomy (RN), compare the modelled results with the results of pure pathologic staging, the Karakiewicz nomogram and the Mayo Clinic Stage, Size, Grade, and Necrosis (SSIGN) score commonly used in foreign countries, and stratify the patients into different prognostic risk subgroups. Methods: A total of 1 246 non-metastatic renal cell carcinoma patients managed with RN in Sun Yat-sen University Cancer Center (SYSUCC) from 1999 to 2020 were retrospectively analyzed. Multivariate Cox regression analysis was used to screen the variables that influence the prognosis for nomogram establishment, and the bootstrap random sampling was used for internal validation. The time-receiver operating characteristic curve (ROC), the calibration curve and the clinical decision curve analysis (DCA) were applied to evaluate the nomogram. The prediction efficacy of the nomogram and that of the pure pathologic staging, the Karakiewicz nomogram and the SSIGN score was compared through the area under the curve (AUC). Finally, patients were stratified into different risk subgroups according to our nomogram scores. Results: A total of 1 246 patients managed with RN were enrolled in this study. Multivariate Cox regression analysis showed that age, smoking history, pathological nuclear grade, sarcomatoid differentiation, tumor necrosis and pathological T and N stages were independent prognostic factors for RN patients (all P<0.05). A nomogram model named SYSUCC based on these factors was built to predict the 5-, 10-, and 15-year survival rate of the participating patients. In the bootstrap random sampling with 1 000 iterations, all these factors occurred for more than 800 times as independent predictors. The Harrell's concordance index (C-index) of SYSUCC was higher compared with pure pathological staging [0.770 (95% CI: 0.716-0.823) vs 0.674 (95% CI: 0.621-0.728)]. The calibration curve showed that the survival rate as predicted by the SYSUCC model simulated the actual rate, while the clinical DCA showed that the SYSUCC nomogram has a benefit in certain probability ranges. In the ROC analysis that included 857 patients with detailed pathological nuclear stages, the nomogram had a larger AUC (5-/10-year AUC: 0.823/0.804) and better discriminating ability than pure pathological staging (5-/10-year AUC: 0.701/0.658), Karakiewicz nomogram (5-/10-year AUC: 0.772/0.734) and SSIGN score (5-/10-year AUC: 0.792/0.750) in predicting the 5-/10-year OS of RN patients (all P<0.05). In addition, the AUC of the SYSUCC nomogram for predicting the 15-year OS (0.820) was larger than that of the SSIGN score (0.709), and there was no statistical difference (P<0.05) between the SYSUCC nomogram, pure pathological staging (0.773) and the Karakiewicz nomogram (0.826). The calibration curve was close to the standard curve, which indicated that the model has good predictive performance. Finally, patients were stratified into low-, intermediate-, and high-risk subgroups (738, 379 and 129, respectively) according to the SYSUCC nomogram scores, among whom patients in intermediate- and high-risk subgroups had a worse OS than patients in the low-risk subgroup (intermediate-risk group vs. low-risk group: HR=4.33, 95% CI: 3.22-5.81, P<0.001; high-risk group vs low-risk group: HR=11.95, 95% CI: 8.29-17.24, P<0.001), and the high-risk subgroup had a worse OS than the intermediate-risk group (HR=2.63, 95% CI: 1.88-3.68, P<0.001). Conclusions: Age, smoking history, pathological nuclear grade, sarcomatoid differentiation, tumor necrosis and pathological stage were independent prognostic factors for non-metastasis renal cell carcinoma patients after RN. The SYSUCC nomogram based on these independent prognostic factors can better predict the 5-, 10-, and 15-year OS than pure pathological staging, the Karakiewicz nomogram and the SSIGN score of patients after RN. In addition, the SYSUCC nomogram has good discrimination, agreement, risk stratification and clinical application potential.

Long-term survival analysis of 1 367 patients treated with radical nephrectomy from a single center / 中华肿瘤杂志

Objective: To report the long-term survival of renal cell carcinoma (RCC) patients treated with radical nephrectomy in Sun Yat-sen University Cancer Center. Methods: We retrospectively analyzed the clinical, pathological and follow-up records of 1 367 non-metastatic RCC patients treated with radical nephrectomy from 1999 to 2020 in this center. The primary endpoint of this study was overall survival rate. Survival curves were estimated using the Kaplan-Meier method, and group differences were compared through Log-rank test. Univariate and multivariate Cox analysis were fit to determine the clinical and pathological features associated with overall survival rate. Results: A total of 1 367 patients treated with radical nephrectomy with complete follow-up data were included in the study. The median follow-up time was 52.6 months, and 1 100 patients survived and 267 died, with the median time to overall survival not yet reached. The 5-year and 10-year overall survival rates were 82.8% and 74.9%, respectively. The 5-year and 10-year overall survival rates of Leibovich low-risk patients were 93.3% and 88.2%, respectively; of Leibovich intermediate-risk patients were 82.2% and 72.3%, respectively; and of Leibovich high-risk patients were 50.5% and 30.2%, respectively. There were significant differences in the long-term survival among the three groups (P<0.001). The 10-year overall survival rates for patients with pT1, pT2, pT3 and pT4 RCC were 83.2%, 73.6%, 55.0% and 31.4%, respectively. There were significant differences among pT1, pT2, pT3 and pT4 patients(P<0.001). The 5-year and 10-year overall survival rates of patients with lymph node metastasis were 48.5% and 35.6%, respectively, and those of patients without lymph node metastasis were 85.1% and 77.5%, respectively. There was significant difference in the long-term survival between patients with lymph node metastasis and without lymph node metastasis. The 10-year overall survival rate was 96.2% for nuclear Grade 1, 81.6% for nuclear Grade 2, 60.5% for nuclear Grade 3, and 43.4% for nuclear Grade 4 patients. The difference was statistically significant. There was no significant difference in the long-term survival between patients with localized renal cancer (pT1-2N0M0) who underwent open surgery and minimally invasive surgery (10-year overall survival rate 80.5% vs 85.6%, P=0.160). Multivariate Cox analysis showed that age≥55 years (HR=2.11, 95% CI: 1.50-2.96, P<0.001), T stage(T3+ T4 vs T1a: HR=2.37, 95% CI: 1.26-4.46, P=0.008), local lymph node metastasis (HR=3.04, 95%CI: 1.81-5.09, P<0.001), nuclear grade (G3-G4 vs G1: HR=4.21, 95%CI: 1.51-11.75, P=0.006), tumor necrosis (HR=1.66, 95% CI: 1.17-2.37, P=0.005), sarcomatoid differentiation (HR=2.39, 95% CI: 1.31-4.35, P=0.005) and BMI≥24kg/m(2) (HR=0.56, 95%CI: 0.39-0.80, P=0.001) were independent factors affecting long-term survival after radical nephrectomy. Conclusions: The long-term survival of radical nephrectomy in patients with renal cell carcinoma is satisfactory. Advanced age, higher pathological stage and grade, tumor necrosis and sarcomatoid differentiation were the main adverse factors affecting the prognosis of patients. Higher body mass index was a protective factor for the prognosis of patients.

The value of cystatin C in early diagnosis of acute kidney injury and predicting prognosis after radical nephrectomy / 中华泌尿外科杂志

Objective:To investigate the value of cystatin C (Cys-C) in the early diagnosis of acute kidney injury (AKI) after radical nephrectomy and the predictive value for the prognosis of Cys-C based estimated glomerular filtration rate (eGFR Cys-C) after surgery. Methods:The clinical data of 118 patients who underwent unilateral radical nephrectomy in our hospital from January 2019 to December 2020 were retrospectively analyzed. According to the diagnostic criteria of AKI, they were divided into AKI group of 75 cases and no-AKI group of 43 cases. AKI group was (62.7±10.7) years old, with 49 males and 26 females. The no-AKI group was (62.3±12.8) years old, with 21 males and 22 females. The urea nitrogen was (4.9±1.3) mmol/L, creatinine (75.7±14.5)μmol/L, Cys-C (0.85±0.22) mg/L, eGFR Cr(76.3±11.2)ml/(min·1.73m 2), and eGFR Cys-C(101.4±17.4)ml/(min·1.73m 2)in AKI group before operation.In no-AKI group, preoperative urea nitrogen was (4.9±1.5) mmol/L, creatinine (74.5±13.1)μmol/L, Cys-C (0.81±0.29) mg/L, eGFR Cr(78.6±12.5)ml/(min·1.73m 2), and eGFR Cys-C(99.3±18.8)ml/(min·1.73m 2), and there were no significant differences in the values of urea nitrogen, creatinine, Cys-C and eGFR between the two groups before surgery ( P>0.05). ROC curve was used to analyze the diagnostic value of urea nitrogen, creatinine, Cys-C, eGFR calculated based on creatinine and Cys-C at 48h after surgery, and binary Logistic regression was used to analyze the risk factors for AKI. The creatinine status of patients diagnosed with SPS was evaluated 6 months after surgery, based on the definition of Cys-C based eGFR being less than 70% of creatinine-based eGFR(SPS=eGFR Cys-C/ eGFR Cr≤0.7). Results:In AKI group, creatinine was(115.2±22.1)μumol/L, Cys-C (1.8±0.27) mg/L, eGFR Cr (51.6±9.6)ml/(min·1.73m 2), and eGFR Cys-C(43.4±8.5)ml/(min·1.73m 2)48 h after operation. The creatinine was(92.7±13.3)μmol/L, Cys-C(1.3±0.23) mg/L, eGFR Cr(62.2±11.3)ml/(min·1.73m 2), and eGFR Cys-C(61.5±9.5)ml/(min·1.73m 2) in no-AKI group, and difference were statistically significant between the two groups ( P<0.01). ROC curve was used to analyze the diagnosis of AKI. Creatinine, Cys-C, eGFR Cr and eGFR Cys-Cwere all of diagnostic value for AKI (all P<0.01), and AUC(Area under curve) were 0.809, 0.889, 0.761 and 0.925 respectively. The sensitivity, specificity and area under the curve of eGFR Cys-C were 93.3%, 74.4% and 92.5% respectively. Binary Logistic regression analysis showed that creatinine( OR=10.851, 95% CI 2.322-50.688, P=0.004), Cys-C( OR=10.016, 95% CI 2.306-43.362, P=0.001), eGFR Cr( OR=17.923, 95%CI 3.216-53.172, P=0.001) and eGFR Cys-C( OR=19.817, 95% CI 3.367-55.263, P=0.001)were all independent risk factors for AKI. The predictive accuracy of eGFR Cys-C, creatinine, Cys-C, eGFR Cr were 91.6%, 85.7%, 90.2%, 88.5%, respectively. There were 15 cases were confirmed SPS in the AKI group, and only 2 cases were confirmed SPS in the no-AKI group, indicating patients in the AKI group developed more SPS than those in the no-AKI group, with statistically significant difference(Kappa value was 5.22, P=0.02). The 6-month follow-up showed that the creatinine of confirmed SPS was (103.8±23.4)μmol/L and the creatinine of unconfirmed SPS was (86.8±27.2)μmol/L, with statistically significant difference ( P<0.01). Conclusions:eGFR Cys-C calculated based on Cys-C has high sensitivity in diagnosing AKI and has early diagnostic value. Patients diagnosed with SPS based on eGFR Cys-C had higher creatinine 6 months after surgery.

Primary renal ewing sarcoma in a 15-year-old female: Case report

@#Extraskeletal Ewing sarcoma (EES) is a rare tumor that primarily affects children and lacks specific clinical signs. Diagnosis is confirmed through imaging techniques, histology, and molecular diagnostics. Treatment typically involves surgical intervention and chemotherapy. We present the case of a 15-year-old female with a history of abnormal mass enlargement in the right flank area. An initial diagnosis of Wilms tumor was made, and the patient underwent a right open radical nephrectomy. However, the tumor recurred eight months after nephrectomy, necessitating a metastasectomy. Chemotherapy was started to immediately target the tumor recurrence. Next-generation sequencing done on the open radical nephrectomy and metastasectomy samples revealed the presence of the EWSR1-FLI1 fusion gene in both specimens, confirming the final diagnosis to be primary renal Ewing sarcoma. Despite undergoing a right open radical nephrectomy for the primary tumor site, a metastasectomy during tumor recurrence, and chemotherapy, the patient’s prognosis remained poor.

Clinical analysis of MAP in transabdominal laparoscopic radical nephrectomy of renal cell carcinoma / 现代泌尿外科杂志

【Objective】 To evaluate the significance of Mayo adhesive probability (MAP) in predicting surgical difficulty and postoperative recovery in patients with renal cell carcinoma (RCC) undergoing laparoscopic radical nephrectomy (LRN). 【Methods】 The clinical data of 168 RCC patients who received transabdominal LRN during Jan.2017 and Dec.2020 were retrospectively analyzed. According to MAP, the patients were divided into low MAP group (n=100) and high MAP group (n=68). The differences in perioperative clinical data were compared between the two groups. 【Results】 Compared with low MAP group, the high MAP group had longer operation time (P<0.001), more intraoperative blood loss (P<0.001), higher Clavien-Dindo grade complications (P=0.008), longer hospital stay (P=0.003), higher levels of c-reactive protein (P=0.030) and IL-6 (P=0.009), lower levels of albumin (P<0.001) and prealbumin (P=0.020). 【Conclusion】 MAP can assess the risk of prolonged operation time, increased bleeding during transabdominal LRN, and postoperative recovery, thus guiding the preoperative planning.

Diagnosis and treatment progress of nephron-sparing surgery in the treatment of upstaging pT3a renal carcinoma / 现代泌尿外科杂志

Nephron-sparing surgery (NSS) is the standard treatment method for T1 and some T2 stage renal cell carcinoma (RCC), but it is not recommended for T3 stage RCC. Due to the limited sensitivity and specificity of preoperative imaging, some cT1/2 upstaging to pT3a RCC patients also receive NSS. The efficacy of NSS versus radical nephrectomy for upstaging to T3a RCC remains highly controversial. This article summarizes the preoperative imaging diagnostic criteria of T3a RCC and risk factors of upstaging to pT3a, and compares the efficacy and prognosis between NSS and radical nephrectomy for upstaging to pT3a RCC.

Key surgical techniques in robot-assisted laparoscopic radical nephrectomy and thrombectomy for renal cell carcinoma with inferior vena cava thrombus / 现代泌尿外科杂志

The mainstay of treatment for renal cell carcinoma with inferior vena cava (IVC) thrombus is complete surgical excision, which can be facilitated by appropriate preoperative evaluation and detailed planning. The level of tumor thrombus, the presence or absence of thrombus and the invasion of vein wall are important variables affecting surgery. For cases complicated with adherent or invasive tumor thrombus, en bloc resection of the IVC with or without venous reconstruction represents a special decision-making. This review will describe the evolving surgical techniques and key points of robotic-assisted radical nephrectomy with IVC thrombectomy.

Influencing factors of conversion from robot-assisted partial nephrectomy to radical nephrectomy / 现代泌尿外科杂志

【Objective】 To explore the influencing factors of planned robot-assisted partial nephrectomy (RAPN) converted to radical nephrectomy (RN). 【Methods】 Clinical data and operation records of 488 patients planned for RAPN in our hospital during 2015 and 2020 were retrospectively collected. The patients were divided into converted and unconverted groups, and relevant clinical data of the two groups were compared. The causes and influencing factors for conversion were analyzed. 【Results】 Among the 488 patients, 14 (2.9%) converted to RN. The causes included: ①complicated tumor anatomy and surgical difficulties; ②local advanced renal tumor suspected during operation; ③severe intraoperative hemorrhage. Univariate analysis showed that R. E. N. A. L score (P<0.001), E value (P<0.001), N value (P<0.001), L value (P<0.001), renal hilum position (P<0.001) and T stage (P=0.002) were influencing factors of conversion. 【Conclusion】 Causes for the conversion of RAPN to RN include complicated tumor anatomy, suspected local advanced renal tumor and severe intraoperative hemorrhage. The R. E. N. A. L score, E value, N value, L value, renal hilum position and T stage are influencing factors.

Comparison of robot-assisted and open surgery in the treatment of renal carcinoma with Mayo Ⅰ-Ⅲ inferior vena cava tumor thrombus / 现代泌尿外科杂志

【Objective】 To compare the clinical efficacy of robot-assisted and open surgery in the treatment of renal carcinoma with inferior vena cava cancer thrombus, and to analyze the safety and feasibility of robot-assisted radical nephrectomy. 【Methods】 Clinical data of 55 patients surgically treated for renal carcinoma with Mayo Ⅰ-Ⅲ inferior vena cava tumor thrombus during Dec.2015 and Dec.2021 were retrospectively analyzed. Based on the operation methods, the patients were divided into the robotic surgery group (n=36) and open surgery group (n=19). The perioperative data, oncological results and survival of the two groups were compared. 【Results】 All operations were successful. The median operation time was 176 (IQR:137-234) min, and grade Ⅲ and above complications occurred in 9(16.4%) cases. The robotic surgery group had lower intraoperative blood loss [300 (IQR:200-625) mL vs.1 000 (IQR:600-1 184) mL] and blood transfusion ratio [(20/36) vs. (18/19)] than the open surgery group, but higher postoperative hemoglobin level[109(98-120) g/L vs. 90(84-100) g/L]. During a median follow-up of 26 (IQR:19-39) months, 19(34.5%) patients developed new metastases and 12(21.8%) patients died. The postoperative tumor-specific survival (HR=0.39, 95%CI:0.13-1.16, P=0.090) and overall survival (HR=0.71, 95%CI:0.22-2.23,P=0.554) were not significantly different between the two groups. 【Conclusion】 There are no significant differences in the incidence of postoperative complications, tumor-specific survival and overall survival between robot-assisted and open surgery for Mayo Ⅰ-Ⅲ inferior vena cava tumor thrombus, but the intraoperative blood loss in robotic group is lower than that in the open surgery group.

Comparison of efficacy and safety of PN and RN in the treatment of stage T1b and T2a renal cell carcinoma / 现代泌尿外科杂志

【Objective】 To compare the efficacy, safety and survival of partial nephrectomy (PN) and radical nephrectomy (RN) in the treatment of clinical T1b and T2a renal cell carcinoma (RCC). 【Methods】 A total of 115 patients with stage T1b and T2a RCC treated during Apr.2014 and Jul.2017 were retrospectively analyzed. According to the different surgical methods, the patients were divided into PN group (n=55) and RN group (n=60). The clinical data and prognosis of the two groups were compared. 【Results】 There were no significant differences in the general clinical data and perioperative related factors between the two groups (P>0.05). The incidence of complications was significantly higher in PN group than in RN group (P=0.024), but there was no significant difference in serious complications (Clavien grade ≥3) (P>0.05). In terms of renal function recovery, there was no significant difference in serum creatinine between the two groups before operation (P>0.05), but the serum creatinine was significantly lower in PN group than in RN group on the 1st day, 3rd, 6th and 12th months after operation (P0.05). 【Conclusion】 Both PN and RN are safe and effective in the treatment of stage T1b and T2a RCC, and can achieve good oncological control effects. Compared with RN, PN can fully and effectively protect the postoperative renal function, but it causes more surgical complications. However, there is no significant difference in severe complications (Clavien grade ≥3).

Comparison between robot-assisted and open radical nephrectomy in the treatment of complex kidney neoplasm >8 cm in diameter / 现代泌尿外科杂志

【Objective】 To compare the feasibility, safety, and efficacy of robot-assisted and open radical nephrectomy for complex kidney neoplasm >8 cm in diameter. 【Methods】 Clinical data of 24 patients with large kidney neoplasm undergoing robot-assisted radical nephrectomy (9 cases, 37.5%) and open radical nephrectomy (15 cases, 62.5%) during Nov.2015 and Aug.2019 were retrospectively analyzed. The surgical parameters, perioperative complications and follow-up outcomes were compared between the two groups. 【Results】 All operations were successful. Compared with the robot group, the open group had a higher incidence of clinical symptoms (93.3% vs.44.4%, P=0.015) and larger maximum tumor diameter (124 mm vs.95 mm, P=0.021). There were no significant differences in other preoperative characteristics between the two groups. The robot group had less intraoperative blood loss (100 mL vs.800 mL, P=0.006) and lower blood transfusion rate (0% vs. 60.0%, P=0.007) than the open group. During the median follow-up of 50 (range: 25-67) months, 4 patients in the open group and 1 in the robot group developed new metastases, and 4 patients in the open group died due to advanced tumor stage. 【Conclusion】 Robot-assisted radical nephrectomy is safe in the treatment of complex and large renal tumors, and causes less intraoperative blood loss than open surgery.

Dexmedetomidine can not reduce the incidence of acute and chronic kidney disease after laparoscopic radical nephrectomy: a propensity score matching-based analysis / 南方医科大学学报

OBJECTIVE@#To investigate the effect of dexmedetomidine (DEX) on renal function after laparoscopic radical nephrectomy.@*METHODS@#We reviewed the clinical data of 282 patients with renal cell carcinoma (RCC), who underwent laparoscopic radical nephrectomy (LRN) in the Department of Urology, Third Medical Center of PLA General Hospital from November, 2020 and June, 2022.According to whether DEX was used during the operation, the patients were divided into DEX group and control group, and after propensity score matching, 99 patients were finally enrolled in each group.The incidence of acute kidney injuries were compared between the two groups.Serum creatinine (sCr) data within 3 months to 1 year after the operation were available in 51 patients, including 26 in DEX group and 25 in the control group, and the incidence of chronic kidney disease (CKD) was compared between the two groups.@*RESULTS@#After propensity score matching and adjustment for significant covariates, there were no significant differences in postoperative levels of sCr, cystatin C (CysC), β2-microglobulin (β2-MG), hemoglobin (Hb), or C-reactive protein (CRP), extubation time, incidence of AKI, or length of hospital stay between the two groups (P>0.05).The intraoperative urine volume was significantly higher in DEX group than in the control group (P < 0.05).A significant correlation between AKI and CKD was noted in the patients (P < 0.05).The incidence of CKD did not differ significantly between the two groups (P>0.05).@*CONCLUSION@#DEX can not reduce the incidence of AKI or CKD after LRN.

Renal functional compensation after unilateral radical nephrectomy of renal cell carcinoma / 北京大学学报(医学版)

OBJECTIVE@#To investigate factors influencing renal functional compensation(RFC) of the preserved kidney after radical nephrectomy (RN).@*METHODS@#A total of 286 patients treated with RN in Peking University People's Hospital were retrospectively analyzed. Preoperative body mass index (BMI), systolic blood pressure (SBP), history of smoking, history of chronic diseases and other basic information, as well as preoperative blood biochemistry, urine routine, imaging examination results were recorded. All the patients underwent 99mtechnetium-diethylenetriamine pentaacetic acid (99mTc-DTPA) renal scans before operation. The surgical method, pathology and blood creatinine values from 1 month to 60 months after RN were recorded. Preoperative and postoperative estimated glomerular filtration rate (eGFR) was calculated by the chronic kidney disease epidemiology collaboration (CKD-EPI) formula. Renal functional compensation was defined as percent change in eGFR of the preserved kidney after RN compared with the preoperative eGFR. Univariate and multivariate regression analyses were used to identify predictive factors of RFC.@*RESULTS@#Median age was 61 years and 65.4% of the patients were male. Early stage (T1 or T2) tumors were found in 83.6% of the cases. 18.5% of the patients had preoperative diabetes mellitus, 39.5% had hypertension, 19.2% had a history of smoking, and 27.6% were found to have renal cyst on the contralateral side. In the study, 226 cases underwent laparoscopic radical nephrectomy and 60 cases underwent open radical nephrectomy. Renal clear cell carcinoma was the most common pathological type, accounting for 88.5%. The median tumor maximum diameter was 4.5 cm (0.7-13.5 cm). Median renal function compensation was 27% one month after radical nephrectomy. Functional stability was then observed to 5 years. The results of univariate analysis showed that age, gender, preoperative blood uric acid, preoperative urine protein, contralateral renal cyst, and percentage of split renal function of contralateral kidney were correlated with RFC (P < 0.05). Among them, UA level and split renal function of contralateral kidney were strongly negatively correlated with RFC. The results of multivariate linear regression analysis showed age (P < 0.001), blood uric acid (P < 0.001), urine protein (P=0.002), preoperative eGFR (P < 0.001) and the split renal function of contralateral kidney (P < 0.001) were independent predictors of RFC.@*CONCLUSION@#The basic examinations, such as blood biochemistry, urine routine and renal scan before RN are of great significance in predicting the compen-satory ability of the preserved kidney after RN, which is supposed to be taken into consideration when making clinical decision.

Application of enhanced recovery after surgery during perioperative period of retroperitoneal laparoscopic radical nephrectomy / 国际外科学杂志

Objective:To investigate the effectiveness of enhanced recovery after surgery (ERAS) concept in perioperative period of retroperitoneal laparoscopic radical nephrectomy.Methods:The clinical data of 189 patients who underwent retroperitoneal laparoscopic radical nephrectomy from October 2015 to July 2021 were retrospectively analyzed. According to different perioperative management methods, they were divided into two groups: ERAS group ( n=97) and traditional group ( n=92). Patients of ERAS group were managed by the ERAS concept during the perioperative period, patients of traditional group were managed by the traditional method during the perioperative period. First drinking time after surgery, first exhaust time, 24 h postoperative pain score, first activity time out of bed, indwelling time of urinary catheter, indwelling time of drainage tube, postoperative hospital stay, incision length and complications of pneumonia and venous thrombosis were recorded and compared between the two groups. Measurement data were expressed as mean ± standard deviation ( Mean± SD), and independent sample t-test was used for comparison between groups; count data comparison between groups was by Chi-square test or Fisher exact probability method. Results:There were no significant differences in age, gender, body mass index, tumor side, tumor diameter, maximum diameter of samples, T stage, diabetes and hypertension from between two groups ( P >0.05). In ERAS group, the time of first drinking water after surgery was (3.8±1.4) h, the time of first anal exhaust was (10.2±2.5) h, the 24 h pain score was (2.4±1.0), the time of first activity out of bed after surgery was (18.8±3.6) h, the indwelling time of urinary catheter was (19.8±3.7) h, the indwelling time of drainage tube was (3.4±0.5) d, the surgical incision length was (7.2±0.9) cm, and the postoperative hospital stay was (5.5±0.6) d. In the traditional group, the time of first drinking water after surgery was (21.2±4.2) h, the time of first anal exhaust was (20.1±4.3) h, the 24 h pain score was (5.4±1.0), the time of first activity out of bed after surgery was (32.8±7.8) h, the indwelling time of urinary catheter was (55.7±8.0) h, the indwelling time of drainage tube was (4.2±0.5) d, the surgical incision length was (13.6±1.5) cm, and the postoperative hospital stay was (7.2±1.3) d. There were statistically significant differences in these indexes between the two groups ( P<0.05). Conclusion:The clinical application of the concept of ERAS during the perioperative period can promote the rapid postoperative recovery of patients undergoing retroperitoneal laparoscopic radical nephrectomy, and can effectively reflect the minimally invase advantages of retroperitoneal laparoscopic technology.

Bilateral renal cell carcinoma operated as right radical nephrectomy and left partial nephrectomy with histopathologically confirmed R0 resection

Bilateral renal tumors remain relatively uncommon, accounting for 1-5% of patients with renal cell carcinoma. Most sporadic renal cell carcinomas are unilateral and unifocal. Bilateral involvement can be synchronous or asynchronous and is found in 2-4% of sporadic renal cell carcinomas. We report a case of 70 years old male who was incidentally found to have bilateral renal masses. Right sided radical nephrectomy and left partial nephrectomy was performed. Histopathological examination of the specimen revealed clear cell carcinoma and confirmed R0 resection. The patient was discharged on 7th postoperative day.