ABSTRACT
INTRODUCTION AND OBJECTIVE: Nephrectomy and venous thrombectomy is a challenging procedure with potential morbidity and mortality. Despite the increasing use of immune checkpoint inhibitors (ICI) in the management of advanced renal cell carcinoma (RCC), data regarding the outcomes of venous thrombectomy following ICI is limited. We evaluated the feasibility and perioperative outcomes of nephrectomy and venous thrombectomy following ICIs. METHODS: Patients with locally advanced or metastatic RCC with venous thrombus undergoing nephrectomy following ICI therapy were evaluated in four high-volume US academic centers between June 2017 and June 2021. Clinical data, perioperative outcomes, and 90-day complications were recorded. RESULTS: Out of 79 patients who received post-ICI nephrectomy, 27 had venous thrombus. Median (IQR) age was 64 (55-71) years. ICI regimens were Nivolumab ± Ipilimumab (n=19), and Pembrolizumab± Axitinib (n=8). Nephrectomy was indicated following either a good clinical response to ICI (n=24) or as a palliative surgery (n=3). Venous thrombi levels are shown in Table-1. Among all patients, 26 (96%) underwent radical and 1 (4%) partial nephrectomy;12 (44.5%) open, 12 (44.5%) robotic and 3 (11%) laparoscopic. One robotic case converted electively to open. Vascular procedures included renal vein thrombectomy (n=6), IVC thrombectomy and primary repair (n=19), IVC patch repair (n=1), and suprarenal cavectomy (n=1). No intraoperative complications were reported. Nine patients showed no viable tumor in the thrombus, of whom 2 had complete response in the primary tumor as well (ypT0N0). 90-day complication rate was 33% (n=9), with 8 patients (30%) requiring readmission (Table-2). One death was reported within 90 days due to COVID-19 infection. CONCLUSIONS: Nephrectomy and venous thrombectomy following systemic immune checkpoint inhibitor therapy is feasible. One third of patients show no viable tumor in the thrombus. Larger studies are needed to predict pathological response.
ABSTRACT
INTRODUCTION AND OBJECTIVE: The COVID-19 pandemic prompted a transition to telehealth in Urology. No study has analyzed urologic surgical outcomes among patients evaluated preoperatively via telehealth only. We compared surgical outcomes between patients who had telehealth only versus in-person preoperative visits prior to urologic surgery. METHODS: Retrospective single center review of all urologic surgeries from April-December 2020. Cases were classified based on whether patients visited preoperatively in person or via telehealth. Major exclusion criteria included having both preoperative in person and telehealth visits. Cases were stratified into four categories for analysis based on CPT coding: Upper Tract Endoscopic (UTE), Lower Tract Endoscopic (LTE), Major Abdominal (MA) (Open/ Laparoscopic/Robotic), and Lower Tract Reconstructive (LTR). Covariates of interest included age, sex, race, ASA status, and distance from hospital. Outcomes included need for blood products, complications, operative time, and length of stay (LOS). Complications were identified using reported morbidity and mortality data and organized based on the Clavien-Dindo scale;scores >2 were considered major complications. RESULTS: Table 1 displays demographic and outcomes of interest. 1,405 patients met inclusion criteria with 101 visits being telehealth only. There was no difference in sex, race, and ASA status. Telehealth patients were younger and lived farther away from the hospital and more likely to undergo UTE or MA surgeries compared to in person visits. There was no difference in perioperative complications or transfusion events between groups. Stratified by procedure type, there was no difference operative time or LOS between cohorts for UTE, MA, or LTE surgeries. LTR surgeries were associated with shorter operative times for telehealth patients, but no difference in LOS. CONCLUSIONS: Patients seen preoperatively by telehealth alone experienced no difference in complications or length of stay when undergoing urologic surgery, including major abdominal surgery. Despite limitations in selection bias and its retrospective nature, our study suggests that telehealth based preoperative evaluation is feasible and safe in appropriately selected patients undergoing urologic surgery.