ABSTRACT
PURPOSE: To compare the outcomes of PN to those of RN in very elderly patients treated for clinically localized renal tumor. PATIENTS AND METHODS: A purpose-built multi-institutional international database (RESURGE project) was used for this retrospective analysis. Patients over 75 years old and surgically treated for a suspicious of localized renal with either PN or RN were included in this database. Surgical, renal function and oncological outcomes were analyzed. Propensity scores for the predicted probability to receive PN in each patient were estimated by logistic regression models. Cox proportional hazard models were estimated to determine the relative change in hazard associated with PN vs RN on overall mortality (OM), cancer-specific mortality (CSM) and other-cause mortality (OCM). RESULTS: A total of 613 patients who underwent RN were successfully matched with 613 controls who underwent PN. Higher overall complication rate was recorded in the PN group (33% vs 25%; p = 0.01). Median follow-up for the entire cohort was 35 months (interquartile range [IQR] 13-63 months). There was a significant difference between RN and PN in median decline of eGFR (39% vs 17%; p < 0.01). PN was not correlated with OM (HR = 0.71; p = 0.56), OCM (HR = 0.74; p = 0.5), and showed a protective trend for CSM (HR = 0.19; p = 0.05). PN was found to be a protective factor for surgical CKD (HR = 0.28; p < 0.01) and worsening of eGFR in patients with baseline CKD. Retrospective design represents a limitation of this analysis. CONCLUSIONS: Adoption of PN in very elderly patients with localized renal tumor does not compromise oncological outcomes, and it allows better functional preservation at mid-term (3-year) follow-up, relative to RN. Whether this functional benefit translates into a survival benefit remains to be determined.
Subject(s)
Carcinoma, Renal Cell/surgery , Kidney Neoplasms/surgery , Neoplasm Staging , Nephrectomy/methods , Postoperative Complications/epidemiology , Propensity Score , Age Factors , Aged , Asia/epidemiology , Carcinoma, Renal Cell/diagnosis , Carcinoma, Renal Cell/physiopathology , Europe/epidemiology , Female , Glomerular Filtration Rate , Humans , Incidence , Kidney Neoplasms/diagnosis , Kidney Neoplasms/physiopathology , Male , Middle Aged , North America/epidemiology , Retrospective Studies , Survival Rate/trends , Treatment OutcomeABSTRACT
OBJECTIVE: To compare the outcomes of robotic radical nephrectomy (RRN) to those of laparoscopic radical nephrectomy (LRN) for large renal masses. METHODS: This was a retrospective analysis of RRN and LRN cases performed for large (≥ cT2) renal masses from 2004 to 2017 and collected in the multi-institutional international database (ROSULA: RObotic SUrgery for LArge renal masses). Peri-operative, functional, and oncologic outcomes were compared between each approach. Descriptive analyses were performed and presented as medians with interquartile ranges. Inverse probability of treatment weighting-adjusted multivariable analyses were used to identify predictors of peri-operative complications. Kaplan-Meier analysis and Cox regression models were used to assess survival outcomes. RESULTS: A total of 941 patients (RRN = 404, LRN = 537) were identified. There was no difference in terms of gender, age, and clinical tumor size. Over the study period, RRN had an annual increase of 11.75% (95% CI [7.34, 17.01] p < 0.001) and LRN had an annual decline of 5.39% (95% CI [-6.94, -3.86] p < 0.001). Patients undergoing RRN had higher BMI (27.6 [IQR 24.8-31.1] vs. 26.5 [24.1-30.0] kg/m2, p < 0.01). Operative duration was longer for RRN (185.0 [150.0-237.2] vs. 126 [90.8-180.0] min, p < 0.001). Length of stay was shorter for RRN (3.0 [2.0-4.0] vs. 5.0 [4.0-7.0] days, p < 0.001). RRN cases presented more advanced disease (higher pathologic staging [pT3-4 52.5 vs. 24.2%, p < 0.001], histologic grade [high grade 49.3 vs. 30.4%, p < 0.001], and rate of nodal disease [pN1 5.4 vs. 1.9%, p < 0.01]). Surgical approach did not represent an independent risk factor for peri-operative complications (OR 1.81 95% CI [0.97-3.39], adjusted p = 0.2). The main study limitation is the retrospective design. CONCLUSIONS: This study represents the largest known multi-center comparison between RRN and LRN. The two procedures seem to offer similar peri-operative outcomes. Notably, RRN has been increasingly utilized, especially in the setting of more advanced and surgically challenging disease without increasing the risk of peri-operative complications.
Subject(s)
Kidney Neoplasms/surgery , Laparoscopy , Nephrectomy/methods , Robotic Surgical Procedures , Aged , Female , Humans , Male , Middle Aged , Retrospective Studies , Treatment OutcomeABSTRACT
Systemic therapy strategies in the setting of localized and locally advanced renal cell carcinoma have continued to evolve in two directions: (i) as adjuvant therapy (to reduce the risk of recurrence or progression in high-risk localized groups); or (ii) as neoadjuvant therapy as a strategy to render primary renal tumors amenable to planned surgical resection in settings where radical resection or nephron-sparing surgery was not thought to be safe or feasible. In the realm of adjuvant therapy, the results of adjuvant therapy phase III randomized clinical trials have been mixed and contradictory; nevertheless, the findings of the landmark Sunitinib Treatment of Renal Adjuvant Cancer study have led to approval of sunitinib as an adjuvant agent in the USA. In the realm of neoadjuvant therapy, presurgical tumor reduction has been shown in a number of phase II studies utilizing targeted molecular agents and in a recently published small randomized double-blind placebo-controlled study, and an expanding body of literature suggests benefit in select patients. Thus, large randomized clinical trial data are not present to support this approach, and guidelines for use of presurgical therapy have not been promulgated. The advent of immunomodulation through checkpoint inhibition represents an exciting horizon for adjuvant and neoadjuvant strategies. The present article reviews the current status and future prospects of adjuvant and neoadjuvant therapy in localized and locally advanced renal cell carcinoma.
Subject(s)
Antineoplastic Agents/therapeutic use , Carcinoma, Renal Cell/therapy , Kidney Neoplasms/therapy , Sunitinib/therapeutic use , Carcinoma, Renal Cell/pathology , Chemotherapy, Adjuvant , Humans , Kidney Neoplasms/pathology , Neoadjuvant Therapy , Randomized Controlled Trials as TopicABSTRACT
OBJECTIVE: To describe the utilization and compare quality outcomes of partial nephrectomy (PN) for cT1a, cT1b and cT2a renal masses using a large national database. METHODS: We conducted a retrospective analysis of patients from the US National Cancer Database who underwent PN for cT1a/cT1b/T2a renal cell carcinoma between 2004 and 2013. We examined the use of PN over time and assessed quality indicators [positive surgical margin (PSM) and 30-day postoperative readmission rates]. Multivariable analysis was conducted to determine predictors for outcome comparisons. RESULTS: A total of 43 749 patients underwent PN for cT1a, cT1b and cT2a renal masses (cT1a, n = 34 796; cT1b, n = 8 040; cT2a, n = 913). The proportion of patients undergoing PN increased from 30.8% in 2004 to 56.7% in 2013 (P < 0.001), and this trend was apparent for all clinical stages. The PSM rate was 6.8%. Predictive factors for increased risk of PSMs included cT1a stage (P = 0.03), age [odds ratio (OR) 1.01; P < 0.001] and later year of diagnosis (OR: 1.05; P < 0.001). The 30-day readmission rate was 4.2%. Predictive factors for increased risk of readmission included cT1b (P < 0.001), high Charlson comorbidity score (OR: 1.32; P = 0.001) and lack of private insurance (OR: 1.21-1.97; P < 0.05); later year of diagnosis was associated with decreased odds of readmission (OR: 0.96; P < 0.001). Subset analysis of the 2010-2013 cohort showed increases in the proportion of minimally invasive PN for cT1a (52.8-69.6%; P < 0.001), cT1b (39.9-59.6%; P < 0.001) and cT2a tumours (33.3-47.3%; P = 0.01). The PSM rate was also increased, at 7.3%. Predictive factors for PSMs included increasing age (OR: 1.01; P < 0.001), minimally invasive surgical approach (OR: 1.52; P < 0.001), and conversion to open surgery (OR: 1.52; P = 0.01), but not clinical stage (P = 0.75-0.99). The 30-day readmission rate was 4.0%. Predictive factors for readmission included lack of private insurance (P < 0.001) and conversion to open surgery (OR: 1.63; P < 0.001). CONCLUSION: The use of PN has increased significantly over time for all clinical stage groups. PSM rates increased, while 30-day readmission rates decreased. The PSM rate increase was driven by increasing use of minimally invasive approaches, and not by higher clinical stage. The 30-day readmission rate was driven by patient comorbidities and socio-economic factors. Rising PSM rates represent a quality-of-care concern.
Subject(s)
Carcinoma, Renal Cell , Kidney Neoplasms , Nephrectomy , Carcinoma, Renal Cell/epidemiology , Carcinoma, Renal Cell/surgery , Databases, Factual , Female , Humans , Kidney Neoplasms/epidemiology , Kidney Neoplasms/surgery , Male , Nephrectomy/adverse effects , Nephrectomy/methods , Nephrectomy/statistics & numerical data , Patient Readmission/statistics & numerical data , Postoperative Complications , Treatment OutcomeABSTRACT
BACKGROUND: We compared renal functional outcomes of robotic (RPN) and open partial nephrectomy (OPN) in patients with chronic kidney disease (CKD), a definite indication for nephron-sparing surgery. METHODS: A multicenter retrospective analysis of OPN and RPN in patients with baseline ≥ CKD Stage III [estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2] was performed. Primary outcome was change in eGFR (ΔeGFR, mL/min/1.73 m2) between preoperative and last follow-up with respect to RENAL nephrometry score group [simple (4-6), intermediate (7-9), complex (10-12)]. Secondary outcomes included eGFR decline > 50%. RESULTS: 728 patients (426 OPN, 302 RPN, mean follow-up 33.3 months) were analyzed. Similar RENAL score distribution (p = 0.148) was noted between groups. RPN had lower median estimated blood loss (p < 0.001), and hospital stay (3 vs. 5 days, p < 0.001). Median ischemia time (OPN 23.7 vs. RPN 21.5 min, p = 0.089), positive margin (p = 0.256), transfusion (p = 0.166), and 30-day complications (p = 0.208) were similar. For OPN vs. RPN, mean ΔeGFR demonstrated no significant difference for simple (0.5 vs. 0.3, p = 0.328), intermediate (2.1 vs. 2.1, p = 0.384), and complex (4.9 vs. 6.1, p = 0.108). Cox regression analysis demonstrated that decreasing preoperative eGFR (OR 1.10, p = 0.001) and complex RENAL score (OR 5.61, p = 0.03) were independent predictors for eGFR decline > 50%. Kaplan-Meier analysis demonstrated 5-year freedom from eGFR decline > 50% of 88.6% for OPN and 88.3% for RPN (p = 0.724). CONCLUSIONS: RPN and OPN demonstrated similar renal functional outcomes when stratified by tumor complexity group. Increasing tumor age and tumor complexity were primary drivers associated with functional decline. RPN provides similar renal functional outcomes to OPN in appropriately selected patients.
Subject(s)
Kidney Neoplasms/surgery , Nephrectomy/methods , Renal Insufficiency, Chronic , Robotic Surgical Procedures , Aged , Female , Glomerular Filtration Rate , Humans , Kidney Neoplasms/complications , Male , Renal Insufficiency, Chronic/complications , Retrospective Studies , Treatment OutcomeABSTRACT
AIMS: We validated a Turkish language version of the urethral stricture surgery specific patient-reported outcome measure (USS-PROM) in men undergoing anterior urethroplasty. We also investigated changes in erectile function (EF) and quality of life (QoL) due to oral mucosa graft (OMG) harvesting. METHODS: The USS-PROM captures lower urinary tract symptoms (LUTS), health related QoL (HRQoL) with EQ-5D visual analogue scale (EQ-VAS). To evaluate EF and OMG morbidity, we used International Index of Erectile Function (IIEF-5) and a self-completed questionnaire, respectively. Psychometric assessment of USS-PROM included test-retest reliability, internal consistency, criterion validity, and responsiveness. Objective evidence for urethroplasty success was demonstrated with fluoroscopic imaging and urethral calibration at post-operative six months. RESULTS: Among the 101 men included during study period, 42 had complete pre- and postoperative 6th month data for analysis. The test-retest intraclass correlation was 0.79. Cronbach's α for internal consistency of the LUTS construct was 0.79. There was a significant negative correlation between total LUTS scores and peak flow rates, both preoperatively (r = -0.478) and postoperatively (r = -0.508). Mean baseline EQ-VAS increased from 70 to 84 postoperatively (P < 0.001), indicating improved HRQoL. IIEF scores did not change significantly after urethroplasty. Early and late-term QoL impairment rates due to OMG harvesting were 28.9 and 13.1%, respectively. Three (7.1%) men required endoscopic intervention for recurrence within 6 months. CONCLUSIONS: Turkish version of USS-PROM showed comparable psychometric properties with the original version. Complementation of this instrument with additional measures that address sexual function and OMG morbidity provides better QoL assessment for urethral reconstruction.
Subject(s)
Erectile Dysfunction/epidemiology , Mouth Diseases/epidemiology , Mouth Mucosa/transplantation , Patient Reported Outcome Measures , Postoperative Complications/epidemiology , Urethra/surgery , Urethral Stricture/surgery , Adult , Aged , Aged, 80 and over , Humans , Lower Urinary Tract Symptoms/physiopathology , Male , Middle Aged , Psychometrics , Quality of Life , Plastic Surgery Procedures , Reproducibility of Results , Surveys and Questionnaires , Urethra/physiopathology , Urethral Stricture/physiopathology , Young AdultABSTRACT
OBJECTIVES: This study aimed to investigate the protective effect and antioxidant activity of an herbal product that made from multiple plants in a rat model of kidney dysfunction induced by intraperitoneal cisplatin. MATERIALS AND METHODS: Twenty-four rats were divided into four different groups namely: Group 1 - control healthy animals without any specific medication, Group 2 - Herbal product only 5 mg/kg, Group 3 - cisplatin only and Group 4 - Herbal product 5 mg/kg + cisplatin. RESULTS: Evaluation of our findings demonstrated a significant (p = 0.017) reduction in Catalase activities and a significant increase (p = 0.001) in renal tissue Malondialdehyde levels in cisplatin- treated rats when compared with the control group. Also, Glutathion and Glutathione peroxidase content revealed significant (p = 0.031) reduction in renal tissues of cisplatintreated rats compared with the control group. Pre-treatment of rats with the herbal product ameliorated these cisplatininduced changes of the antioxidant enzymes. No statistically significant changes were demonstrated in Superoxide dismutase activities in the tissue specimens of any group. CONCLUSIONS: This potent antioxidant herbal medicine was found to have potential antioxidant activity, which may in turn to be effective in the protection of kidney tissue resulting from cisplatin application. Therefore, much attention should be given to the possible role of natural dietary antioxidants for protecting the kidney.
Subject(s)
Antineoplastic Agents/toxicity , Cisplatin/toxicity , Kidney Diseases/prevention & control , Plant Preparations/pharmacology , Animals , Antioxidants/pharmacology , Catalase/metabolism , Glutathione/metabolism , Glutathione Peroxidase/metabolism , Injections, Intraperitoneal , Kidney Diseases/chemically induced , Male , Malondialdehyde/metabolism , Random Allocation , Rats , Rats, WistarABSTRACT
We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13−4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27−0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.
ABSTRACT
BACKGROUND: We sought to analyze the usefulness of pretreatment C-reactive protein (CRP) as a predictor of survival and oncological outcomes in patients with renal cell carcinoma (RCC). METHODS: Retrospective international analysis of patients with RCC with pretreatment CRP values from 2006 to 2017. A CRP of more than >5 mg/L was deemed elevated. The cohort was subdivided into 2 groups for analysis (normal CRP ≤5 mg/L; elevated CRP >5). Primary outcome was overall survival (OS) and secondary outcome was recurrence-free survival (RFS). Kaplan-Meier analyses (KMA) and multivariable analyses (MVA) were used to delineate survival outcomes and their predictors. RESULTS: We analyzed 2445 patients (1641 male/804 female; normal CRP 1056/elevated CRP 1389; mean follow-up 36 months). Patients with elevated CRP had a higher incidence of hypertension (P = .001), higher body mass index (P < .001), and larger tumor size (6.0 cm vs 3.9 cm; P < .001). MVA for RFS demonstrated elevated CRP (hazard ratio [HR], 1.85; P = .005), tumor size (HR, 1.1; P < .001), and high tumor grade (HR, 3.1; P < .001) to be independent risk factors. For normal vs elevated CRP, KMA for RFS of stages 1-4 RCC revealed a 5-year RFS of 93% vs 88% (P = .001), 95% vs 83% (P = .163), 84% vs 62% (P = .001), and 58% vs 60% (P = .513), respectively. KMA MA KMA for OS of stages 1-4 RCC revealed a 5-year OS of 98% vs 81% (P = .001), 94% vs 80% (P = .103), 94% vs 65% (P = .001), and 99% vs 38% (P < .001), respectively. CONCLUSIONS: Pretreatment CRP was an independent predictor of RFS and OS in an international multicenter cohort of patients with RCC.
Subject(s)
Carcinoma, Renal Cell , Kidney Neoplasms , C-Reactive Protein/analysis , Carcinoma, Renal Cell/surgery , Disease-Free Survival , Female , Humans , Kidney Neoplasms/surgery , Male , Nephrectomy , Prognosis , Retrospective StudiesABSTRACT
Available comparison of transperitoneal robot-assisted partial nephrectomy (tRAPN) and retroperitoneal robot-assisted partial nephrectomy (rRAPN) does not consider tumour's location. The aim of this study was to compare perioperative morbidity, and functional and pathological outcomes after tRAPN and rRAPN, with the specific hypothesis that tRAPN for anterior tumours and rRAPN for posterior tumours might be a beneficial strategy. A large global collaborative dataset of 1169 cT1-2N0M0 patients was used. Propensity score matching, and logistic and linear regression analyses tested the effect of tRAPN versus rRAPN on perioperative outcomes. No differences were observed between rRAPN and tRAPN with respect to complications, operative time, length of stay, ischaemia time, median 1-yr estimated glomerular filtration rate (eGFR), and positive surgical margins (all p>0.05). Median estimated blood loss and postoperative eGFR were 50 versus100ml (p<0.0001) and 82 versus 78ml/min/1.73 m2 (p=0.04) after rRAPN and tRAPN, respectively. At interaction tests, no advantage was observed after tRAPN for anterior tumours and rRAPN for posterior tumours with respect to complications, warm ischaemia time, postoperative eGFR, and positive surgical margins (all p>0.05). The techniques of rRAPN and tRAPN offer equivalent perioperative morbidity, and functional and pathological outcomes, regardless of tumour's location. PATIENT SUMMARY: Robot-assisted partial nephrectomy can be performed with a transperitoneal or a retroperitoneal approach regardless of the specific position of the tumour, with equivalent outcomes for the patient.
Subject(s)
Kidney Neoplasms , Nephrectomy/methods , Robotic Surgical Procedures , Humans , Kidney Neoplasms/surgery , Length of Stay , Treatment OutcomeABSTRACT
BACKGROUND: Use of partial nephrectomy (PN) in T3 renal cell carcinoma (RCC) is controversial. OBJECTIVE: To evaluate quality outcomes of robot-assisted PN (RAPN) for clinical T3a renal masses (cT3aRM). DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective multicenter analysis of patients with cT3aN0M0 RCC who underwent RAPN. INTERVENTION: RAPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was a trifecta composite outcome of negative surgical margins, warm ischemia time (WIT) ≤25 min, and no perioperative complications. The optimal outcome was defined as achieving this trifecta and ≥90% preservation of the estimated glomerular filtration rate (eGFR) and no stage upgrading of chronic kidney disease. Multivariable analysis (MVA) identified risk factors associated with lack of the optimal outcome. Kaplan-Meier analysis was conducted for survival outcomes. RESULTS AND LIMITATIONS: Analysis was conducted for 157 patients (median follow-up 26 mo). The median tumor size was 7.0 cm (interquartile range [IQR] 5.0-7.8) and the median RENAL score was 9 (IQR 8-10). Median estimated blood loss (EBL) was 242 ml (IQR 121-354) and the median WIT was 19 min (IQR 15-25). A total of 150 patients (95.5%) had negative margins. Complications were noted in 25 patients (15.9%), with 4.5% having Clavien grade 3-5 complications. The median change in eGFR was 7 ml/min/1.72 m2, with ≥90% eGFR preservation in 55.4%. The trifecta outcome was achieved for 64.3% and the optimal outcome for 37.6% of the patients. MVA revealed that greater age (odds ratio [OR] 1.06; p = 0.002), increasing RENAL score (OR 1.30; p = 0.035), and EBL >300 ml (OR 5.96, p = 0.006) were predictive of failure to achieve optimal outcome. The 5-yr recurrence-free survival, cancer-specific survival, and overall survival, were 82.1%, 93.3%, and 91.3%, respectively. Limitations include the retrospective design. CONCLUSIONS: RAPN for select cT3a renal masses is feasible and safe, with acceptable quality outcomes. Further investigation is requisite to delineate the role of RAPN in cT3a RCC. PATIENT SUMMARY: Robot-assisted partial nephrectomy in patients with stage 3a kidney cancer provided acceptable survival, functional, and morbidity outcomes in the hands of experienced surgeons, and may be considered as an option when clinically indicated.
Subject(s)
Carcinoma, Renal Cell , Kidney Neoplasms , Robotics , Carcinoma, Renal Cell/pathology , Carcinoma, Renal Cell/surgery , Humans , Kidney Neoplasms/pathology , Margins of Excision , Nephrectomy/methods , Retrospective Studies , Treatment OutcomeABSTRACT
OBJECTIVE: The most crucial steps of percutaneous nephrolithotomy (PCNL) are the percutaneous access and dilation of the access route. Recent literature suggests that papillary access to renal calyx is the accepted method. Despite this rule, we do not always make papillary puncture and we puncture wherever we can to achieve stone-free status and reduce unnecessary access. In this study, we present our results with papillary vs non-papillary access in patients with a kidney stone. MATERIAL AND METHODS: Two hundred and seven patients with non-papillary access and 69 patients with papillary access who had similar demographics (age, body mass index (BMI), stone size) were selected with pair match analysis (3:1). Preoperative and postoperative data were collected from the patient's chart. Operative time (from starting surgery to nephrostomy tube), drop-in hematocrit level, transfusion rate, duration of hospital stay, perioperative and postoperative complications (Clavien-Dindo Classification) and stone-free status (no or < 3 mm residual stone) were also evaluated in both groups. RESULTS: The mean operative time was similar in between two groups. The mean hematocrit decreases not differ between the two groups (p = 0.56). In papillary group, only 2 patients (3.2%) required transfusion and only one patient (1.4%) in the non-papillary group had a transfusion with no statistically significant difference (p = 0.43). The overall complication rates were 7.1% in the papillary group and 7.2% in the non-papillary group (p = 0.89). Postoperative mean creatinine level was similar between the two groups. Conclusions: In this study, we found that non-papillary access is a feasible option for PCNL in the terms of stone-free status and complication rates.
Subject(s)
Kidney Calculi/surgery , Kidney Calices/surgery , Nephrolithotomy, Percutaneous/methods , Blood Transfusion/statistics & numerical data , Body Mass Index , Case-Control Studies , Creatinine/blood , Dilatation/methods , Female , Hematocrit , Humans , Kidney Calculi/blood , Length of Stay , Male , Matched-Pair Analysis , Middle Aged , Nephrolithotomy, Percutaneous/adverse effects , Operative Time , Postoperative Complications , Punctures/methods , Retrospective StudiesABSTRACT
BACKGROUND: Partial nephrectomy (PN) in elderly patients is underutilized with concerns regarding risk of complications and potential for poor outcomes. OBJECTIVE: To evaluate quality and functional outcomes of PN in patients >75 yr using trifecta as a composite outcome of surgical quality. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective analysis of 653 patients aged >75 yr who underwent PN (REnal SURGery in Elderly [RESURGE] Group). INTERVENTION: PN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was achievement of trifecta (negative margin, no major [Clavien ≥3] urological complications, and ≥90% estimated glomerular filtration rate [eGFR] recovery). Secondary outcomes included chronic kidney disease (CKD) stage III and CKD upstaging. Multivariable analysis (MVA) was used to assess variables for achieving trifecta and functional outcomes. Kaplan-Meier survival analysis (KMA) was used to calculate renal functional outcomes. RESULTS AND LIMITATIONS: We analyzed 653 patients (mean age 78.4 yr, median follow-up 33 mo; 382 open, 157 laparoscopic, and 114 robotic). Trifecta rate was 40.4% (n=264). Trifecta patients had less transfusion (p<0.001), lower intraoperative (5.3% vs 27%, p<0.001) and postoperative (25.4% vs 37.8%, p=0.001) complications, shorter hospital stay (p=0.045), and lower ΔeGFR (p <0.001). MVA for predictive factors for trifecta revealed decreasing RENAL nephrometry score (odds ratio [OR] 1.26, 95% confidence interval 1.07-1.51, p=0.007) as being associated with increased likelihood to achieve trifecta. Achievement of trifecta was associated with decreased risk of CKD upstaging (OR 0.47, 95% confidence interval 0.32-0.62, p<0.001). KMA showed that trifecta patients had improved 5-yr freedom from CKD stage 3 (93.5% vs 57.7%, p<0.001) and CKD upstaging (84.3% vs 8.2%, p<0.001). Limitations include retrospective design. CONCLUSIONS: PN in elderly patients can be performed with acceptable quality outcomes. Trifecta was associated with decreased tumor complexity and improved functional preservation. PATIENT SUMMARY: We looked at quality outcomes after partial nephrectomy in elderly patients. Acceptable quality outcomes were achieved, measured by a composite outcome called trifecta, whose achievement was associated with improved kidney functional preservation.
Subject(s)
Kidney Neoplasms/surgery , Nephrectomy , Age Factors , Aged , Aged, 80 and over , Glomerular Filtration Rate , Humans , Kidney/physiology , Male , Margins of Excision , Nephrectomy/methods , Postoperative Complications/epidemiology , Retrospective Studies , Treatment Outcome , Urologic Diseases/epidemiologyABSTRACT
The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass. The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used. Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m2. PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01). In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available.
ABSTRACT
Aim and Background: To investigate the association of serum uric acid (SUA) levels along with statin use in Renal Cell Carcinoma (RCC), as statins may be associated with improved outcomes in RCC and SUA elevation is associated with increased risk of chronic kidney disease (CKD). Methods: Retrospective study of patients undergoing surgery for RCC with preoperative/postoperative SUA levels between 8/2005-8/2018. Analysis was carried out between patients with increased postoperative SUA vs. patients with decreased/stable postoperative SUA. Kaplan-Meier analysis (KMA) calculated overall survival (OS) and recurrence free survival (RFS). Multivariable analysis (MVA) was performed to identify factors associated with increased SUA levels and all-cause mortality. The prognostic significance of variables for OS and RFS was analyzed by cox regression analysis. Results: Decreased/stable SUA levels were noted in 675 (74.6%) and increased SUA levels were noted in 230 (25.4%). A higher proportion of patients with decreased/stable SUA levels took statins (27.9% vs. 18.3%, p = 0.0039). KMA demonstrated improved 5- and 10-year OS (89% vs. 47% and 65% vs. 9%, p < 0.001) and RFS (94% vs. 45% and 93% vs. 34%, p < 0.001), favoring patients with decreased/stable SUA levels. MVA revealed that statin use (Odds ratio (OR) 0.106, p < 0.001), dyslipidemia (OR 2.661, p = 0.004), stage III and IV disease compared to stage I (OR 1.887, p = 0.015 and 10.779, p < 0.001, respectively), and postoperative de novo CKD stage III (OR 5.952, p < 0.001) were predictors for increased postoperative SUA levels. MVA for all-cause mortality showed that increasing BMI (OR 1.085, p = 0.002), increasing ASA score (OR 1.578, p = 0.014), increased SUA levels (OR 4.698, p < 0.001), stage IV disease compared to stage I (OR 7.702, p < 0.001), radical nephrectomy (RN) compared to partial nephrectomy (PN) (OR 1.620, p = 0.019), and de novo CKD stage III (OR 7.068, p < 0.001) were significant factors. Cox proportional hazard analysis for OS revealed that increasing age (HR 1.017, p = 0.004), increasing BMI (Hazard Ratio (HR) 1.099, p < 0.001), increasing SUA (HR 4.708, p < 0.001), stage III and IV compared to stage I (HR 1.537, p = 0.013 and 3.299, p < 0.001), RN vs. PN (HR 1.497, p = 0.029), and de novo CKD stage III (HR 1.684, p < 0.001) were significant factors. Cox proportional hazard analysis for RFS demonstrated that increasing ASA score (HR 1.239, p < 0.001, increasing SUA (HR 9.782, p < 0.001), and stage II, III, and IV disease compared to stage I (HR 2.497, p < 0.001 and 3.195, p < 0.001 and 6.911, p < 0.001) were significant factors. Conclusions: Increasing SUA was associated with poorer outcomes. Decreased SUA levels were associated with statin intake and lower stage disease as well as lack of progression to CKD and anemia. Further investigation is requisite.
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OBJECTIVE: To analyze the outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) in octogenarian patients. METHODS: The RESURGE (REnal SUrgery in the Eldely) multi-institutional database was queried to identify patients ≥80 years old who had undergone a PN or RN for a renal tumor. Multivariable binary logistic regression estimated the association between type of surgery and occurrence of complications. Multivariable Cox regression model assessed the association between type of surgery and All-Causes Mortality. RESULTS: The study analyzed 585 patients (median age 83 years, IQR 81-84), 364 of whom (62.2%) underwent RN and 221 (37.8%) PN. Patients undergoing RN were older (Pâ¯=â¯.0084), had larger tumor size (P < .0001) and higher clinical stage (P < .001). At multivariable analysis for complications, the only significant difference was found for lower risk of major postoperative complications for laparoscopic RN compared to open RN (OR: 0.42; Pâ¯=â¯.04). The rate of significant (>25%) decrease of eGFR in PN and RN was 18% versus 59% at 1 month, and 23% versus 65% at 6 months (P < .0001). After a median follow-up time of 39 months, 161 patients (31%) died, of whom 105 (20%) due to renal cancer. CONCLUSION: In this patient population both RN and PN carry a non-negligible risk of complications. When surgical removal is indicated, PN should be preferred, whenever technically feasible, as it can offer better preservation of renal function, without increasing the risk of complications. Moreover, a minimally invasive approach should be pursued, as it can translate into lower surgical morbidity.
Subject(s)
Carcinoma, Renal Cell/surgery , Kidney Neoplasms/surgery , Nephrectomy/methods , Postoperative Complications/epidemiology , Aged, 80 and over , Asia/epidemiology , Carcinoma, Renal Cell/diagnosis , Carcinoma, Renal Cell/mortality , Europe/epidemiology , Female , Follow-Up Studies , Humans , Incidence , Kidney Neoplasms/diagnosis , Kidney Neoplasms/mortality , Male , Neoplasm Staging , Retrospective Studies , Survival Rate/trends , United States/epidemiologyABSTRACT
Neoadjuvant Targeted Molecular Therapy in the setting of localized and locally advanced renal cell carcinoma has emerged as a strategy to render primary renal tumors amenable to planned surgical resection in settings where radical resection or nephron-sparing surgery was not thought to be safe or feasible. Presurgical tumor reduction has been demonstrated in a number of studies including a recently published randomized double-blind placebo-controlled study, and an expanding body of literature suggests benefit in select patients. Nonetheless, most reports are small phase II clinical trials or retrospective reports. Thus, large randomized clinical trial data are not present to support this approach, and guidelines for use of presurgical therapy have not been promulgated. The advent of immunomodulation through checkpoint inhibition represents an exciting horizon for neoadjuvant strategies. This article reviews the current status and future prospects of neoadjuvant therapy in nonmetastatic renal cell carcinoma.
Subject(s)
Carcinoma, Renal Cell/drug therapy , Carcinoma, Renal Cell/therapy , Neoadjuvant Therapy/methods , Carcinoma, Renal Cell/pathology , HumansABSTRACT
OBJECTIVE: To investigate the utility of multiphase computed tomography (CT) and percutaneous renal mass biopsy (PRMB) in differentiating between papillary renal cell carcinoma (pRCC)-Type 1 and -Type 2, as emerging data have suggested differential enhancement patterns in different renal tumor histologies. MATERIAL AND METHODS: Retrospective analysis of 51 patients (23 pRCC-Type 1/28 pRCC-Type 2) who underwent multiphase CT followed by surgery from July 2011 to April 2016 was performed. Data were analyzed between subgroups based on histology. Multiphase CT was analyzed for tumor size, and attenuation [Hounsfield Units (HU)]. Change in HU (ΔHU) was calculated between noncontrast (NC), corticomedullary (CM), nephrographic (N), and delayed (D) phases. Subset analysis was carried out on patients who underwent PRMB prior to surgery. RESULTS: There was no difference in median tumor size (pRCC-Type 1 2.8 vs. pRCC-Type 2 2.6 cm, p=0.832). In addition to tumor size being similar between groups, distribution of tumor stages between groups was also similar (p=0.651). Greater proportion of high-grade tumors (III/IV) was noted in pRCC-Type 2 (42.9% vs. 8.7%) (p=0.011). There was no difference in HU values for NC (p=0.961), CM (p=0.118), N (p=0.277), and D (p=0.256) phases, and in ΔHU between CM-NC (p=0.278), N-NC (p=0.316), and D-NC (p=0.103). Thirteen patients underwent percutaneous biopsy, 11 of whom had diagnostic samples. Examination of 10/11 (90.9%) samples accurately predicted correct histology, and of 6/11 (54.5%) samples correctly identified high-vs. low-grade histology. CONCLUSION: Our findings suggest substantial overlap of CT findings, despite pRCC-Type 2 having greater proportion of high-grade tumors. Utility of CT is limited in the differentiation between pRCC subtypes. Patients with suggested pRCC on CT imaging being considered for a non-extirpative strategy should undergo PRMB for risk stratification.
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BACKGROUND: Sunitinib might optimize the feasibility of partial nephrectomy (PN) for complex renal tumors with imperative indications. We compared the renal functional outcomes of patients with complex renal masses who had undergone sunitinib before PN with those of patients who had not required neoadjuvant sunitinib before PN. PATIENTS AND METHODS: We performed a multicenter retrospective analysis of patients with renal cell carcinoma who had undergone PN for a complex renal mass (R.E.N.A.L. nephrometry score, 10-12) and imperative indications from January 2012 to July 2014. Neoadjuvant sunitinib was used in cases for which PN was not considered feasible. The cohort was divided into those patients who had undergone PN without neoadjuvant sunitinib and those who had undergone PN after sunitinib (no-neoadjuvant vs. neoadjuvant). The change in tumor size and R.E.N.A.L. score were assessed. The primary outcome was the change in the estimated glomerular filtration rate (ΔeGFR) from preoperatively to the last postoperative follow-up visit. RESULTS: The data from 125 consecutive patients were analyzed (47 neoadjuvant and 78 no-neoadjuvant; median follow-up, 21 months). The neoadjuvant plus PN patients had had a greater median tumor size preoperatively (7.2 vs. 6 cm; P = .045). Sunitinib caused a significant decrease in the median tumor size (from 7.2 to 5.8 cm [19.4%]; P = .012) and R.E.N.A.L. score (from 11 to 9; P = .001). No significant differences were found between the neoadjuvant and no-neoadjuvant groups in the ischemia time (P = .413) or incidence of complications (P = .728). The median ΔeGFR was similar (neoadjuvant, 6.4; no-neoadjuvant, 6.1; P = .534). Linear regression analysis for factors associated with an increasing ΔeGFR demonstrated increasing age (estimate, -0.074; P = .009) increasing body mass index (estimate, -0.087; P = .043), and decreasing baseline eGFR (estimate, -0.104; P = .02) as significant factors. CONCLUSION: The use of neoadjuvant sunitinib might facilitate complex PN and result in renal functional outcomes similar to those of patients with a complex renal mass who had not required neoadjuvant sunitinib.