Predictive factors of recurrence after surgery in patients with non-metastatic renal cell carcinoma with venous tumor thrombus (UroCCR-56 Study).

PURPOSE: To assess the oncological outcomes of renal cell carcinoma (RCC) associated with tumor thrombus and identify predictive factors of recurrence. METHODS: Multi-institutional study that included patients with cT3-4N0-1M0 RCC with tumoral thrombus identified in the prospective UroCCR database (CNIL DR 2013-206; NCT03293563). pT3a without involvement of the renal vein were excluded. All patients underwent radical nephrectomy and a thrombectomy of the renal vein ± inferior vena cava ± right atrium. The primary endpoint was recurrence-free survival (RFS). Thirty-two patients who had adjuvant therapies (tyrosine kinase inhibitors or mTOR inhibitor) were compared to control group (surveillance) in a propensity score-matched 1:1 sub-analysis RESULTS: A total of 432 patients were included: 70.4% pT3a, 20.1% pT3b, 4.2% pT3c and 5.3% pT4. Tumor characteristics were: 90.7% clear cell RCC, 13.9% pN1, and 87.1% high Fuhrman grade. 173 patients (40%) had disease recurrence, and median RFS was 37.3 months (95% CI, 26.4-46.7). In a multivariate analysis (Cox model), predictive factors of recurrence were: pT4 (HR 2.66; 95% CI, 1.42-4.99; p = 0.002), pN1 (HR 2.53; 95% CI, 1.46-4.39; p < 0.001), tumor necrosis (HR 2.92; 95% CI, 1.85-4.62; p < 0.001), tumor size > 10 cm (HR 1.56; 95% CI, 1.08-2.24; p = 0.018). Adjuvant therapy was a protective factor of cancer recurrence (HR 0.33; 95% CI, 0.17-0.66; p = 0.002). Propensity score-matched sub-analysis of adjuvant vs control (surveillance) confirmed adjuvant treatment as a protective factor of cancer recurrence (Log rank p = 0.015). CONCLUSIONS: In this contemporary multi-institutional cohort of RCC + tumor thrombus, we reported higher recurrence rate shortly after surgical excision and demonstrated an oncological benefit of adjuvant treatment.

Comparison of 1800 Robotic and Open Partial Nephrectomies for Renal Tumors.

BACKGROUND: Only a few studies have compared the outcomes of robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN). This study aimed to compare perioperative and oncologic outcomes of RPN and OPN. METHODS: The data of all patients who underwent partial nephrectomy from 2006 to 2014 in six academic departments of urology were retrospectively collected. Perioperative outcomes were compared between OPN and RPN patients. Cancer-specific survival (CSS) and recurrence-free survival (RFS) were estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: The study included 1800 patients: 937 who underwent RPN and 863 who underwent OPN. The patients in the robotic group had smaller tumors (33.1 vs. 39.9 mm; p < 0.001) but comparable RENAL scores (6.8 vs. 6.7; p = 0.37). The complication rate was higher in the OPN group (28.6 vs. 18 %; p < 0.001). The OPN patients had greater estimated blood loss (359.5 vs. 275 ml; p < 0.001) and more frequent hemorrhagic complications (12.1 vs. 6.9 %; p < 0.001). The robotic approach was associated with a shorter warm ischemia time (WIT 15.7 vs. 18.6 min; p < 0.001) and a shorter hospital of stay (4.7 vs. 10.1 days; p < 0.001). In the propensity score-weighted analysis, the inverse probability of treatment weighting adjusted odds ratio for the risk of complication after OPN versus RPN was 2.11 (95 % confidence interval, 1.53-2.91; p < 0.001). After a median postoperative follow-up period of 13 months for OPN and 39 months for RPN (p < 0.001), CSS and RFS were similar in the two groups. In the multivariate analysis, RPN showed an impact on the occurrence of a complication but had no effect on WIT or RFS. CONCLUSION: In this study, RPN was less morbid than OPN, with lower complications, less blood loss, and a shorter hospital of stay. The intermediate-term oncologic outcomes were similar in the two groups.

The use of hemostatic agents does not prevent hemorrhagic complications of robotic partial nephrectomy.

PURPOSE: To assess the impact of HA on robotic PN (RPN) outcomes. METHODS: We retrospectively analyzed data from patients who underwent RPN in eight centers between 2009 and 2013. Hemorrhagic complications were defined as the occurrence of a pseudoaneurysm, arteriovenous fistula or hematoma requiring transfusion. Patients were first divided into two groups: group A (use of at least one HA) and group B (no HA used), and then into five groups to assess the impact of each HA: group 1 (no HA), group 2 (Floseal(®) only), group 3 (Surgicel(®) only), group 4 (Tachosil(®) only) and group 5 (Surgicel(®) + Floseal(®)). The impact of HA was evaluated by univariate and multivariate analysis. RESULTS: Out of 515 RPN, 315 (61 %) were done using at least one HA (group A) and 200 (39 %) were done without any HA (group B). Patients in both groups had similar hemorrhagic complication rates (13 % vs. 15 %, p = 0.42) and postoperative complication rates (19 % vs. 23 %, p = 0.32). In multivariate analysis, the absence of HA was not a risk factor for hemorrhagic complications (OR 0.77, p = 0.54). When each type of HA was considered individually, none was associated with the occurrence of hemorrhagic complication either in univariate or in multivariate analysis. CONCLUSION: In this multicenter study, the use of HA was not associated with a lower risk of hemorrhagic or global complications.

Exploring Biological Predictive Factors of Progression After Surgery in High-Risk Renal Cell Carcinoma: Results From the French Cohort of the Randomized S-TRAC Trial Patients.

Objective: We aimed to explore biological predictive factors of progression after surgery in nonmetastatic renal cell carcinoma (RCC) using the collected tumors in the French cohort of the randomized S-TRAC trial patients. Patients and Methods: We analyzed the tumors of the French cohort of STRAC that included 44 cases of clear cell RCC (ccRCC) that were collected from six centers. The main objective was to explore biological predictive factors of progression (defined as PFS) to sunitinib. Broad-spectrum analysis including immunohistochemistry, fluorescent in situ hybridization (FISH), comparative genomic hybridization (CGH) array, and transcriptomic analyses were performed on the tumors. Results:Analysis of vascular density showed type 1 vascular stroma corresponding to high vascular density was associated with progression (p < 0.034). Loss of poly bromo-1 expression showed a distinct profile: a highly histopathological aggressive tumor with a marked angiogenic profile (vascular endothelial growth factor overexpression and immature vascular stroma type 2), no PD1 or PDL1 expression, and wild-type (WT) status of the VHL gene. There were 27 chromosome regions gained in patients with progression (on chromosomes 7 and 16, and to a lesser extent 8, 12, 17, 17, 19, 20 corresponding to 605 associated genes) and 10 regions lost in these same patients on chromosomes 8 and 9, and to a lesser extent 2 and 21 corresponding to 25 associated genes. Conclusion:We found that an angiogenic phenotype defined by a high vascular density with a vascular type 2 stroma was a predictive factor of sunitinib resistance. Regardless of adjuvant treatment, chromosomal gains and losses and genomic alterations including PBRM1 loss were associated with worse outcomes. Clinical Trial Registration: ClinicalTrials.gov number, NCT00375674.

A Fatal Case of Massive Incarcerated Genital Prolapse.

Genital prolapse is usually seen as a benign condition warranting treatment only when bothersome. We report the case of a 77-year-old woman who presented with massive incarcerated pelvic organ prolapse, which led to bladder necrosis, cystectomy with bilateral cutaneous ureterostomy, and death from medical complications 5 weeks after the initial presentation. This first case report of death from bladder necrosis after incarcerated genital prolapse could warrant treatment of massive prolapse even when apparently well tolerated.

Impact of Anticoagulant and Antiplatelet Drugs on Perioperative Outcomes of Robotic-assisted Partial Nephrectomy.

OBJECTIVE: To evaluate the impact of anticoagulant (AC) or antiplatelet (AP) therapy on the morbidity of robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: From 2011 to 2015, we retrospectively analyzed a prospectively maintained institutional review board-approved database of RAPN from 2 academic departments of urology. We evaluated the occurrence of overall complications and hemorrhagic complications (pseudoaneurysm, arteriovenous fistula, hematoma, transfusion). Patients with therapeutic AC or AP, stopped or not before surgery, were compared with patients without therapeutic AC or AP. A logistic regression model was used to identify predictors of complications. RESULTS: Out of 533 patients who underwent RAPN, 70 had AC or AP (50% aspirin, 25% clopidogrel, 28% AC, 8% direct oral AC). Clopidogrel, AC, and direct oral AC were always stopped preoperatively. Aspirin was continued in 25% of the cases. In univariate analysis, overall complications (39.2% vs 17.4%; P = .001) and hemorrhagic complications (32.7% vs 9.6%; P <.001) were higher in patients on AC or AP. Hospital stay was longer in the group with therapeutic AC or AP treatment (5.1 vs 3.9 days; P <.001). In multivariate analysis, predictors of complications were intake of therapeutic AC (odds ratio [OR] = 4.3, IC95% [1.2-15.9], P = .03) and tumor size (OR = 1.8, IC95% [1.3-7.2], P = .03). Patients on aspirin tended to have more complications (OR = 2.4; IC95% [0.4-9.3]; P = .15). CONCLUSION: AP and therapeutic AC increase the morbidity of RAPN. These treatments should be taken into account in treatment decision-making algorithm of small renal masses.