Fully Automated Versions of Clinically Validated Nephrometry Scores Demonstrate Superior Predictive Utility versus Human Scores.

OBJECTIVE: To automate the generation of three validated nephrometry scoring systems on preoperative computerised tomography (CT) scans by developing artificial intelligence (AI)-based image processing methods. Subsequently, we aimed to evaluate the ability of these scores to predict meaningful pathological and perioperative outcomes. PATIENTS AND METHODS: A total of 300 patients with preoperative CT with early arterial contrast phase were identified from a cohort of 544 consecutive patients undergoing surgical extirpation for suspected renal cancer. A deep neural network approach was used to automatically segment kidneys and tumours, and then geometric algorithms were used to measure the components of the concordance index (C-Index), Preoperative Aspects and Dimensions Used for an Anatomical classification of renal tumours (PADUA), and tumour contact surface area (CSA) nephrometry scores. Human scores were independently calculated by medical personnel blinded to the AI scores. AI and human score agreement was assessed using linear regression and predictive abilities for meaningful outcomes were assessed using logistic regression and receiver operating characteristic curve analyses. RESULTS: The median (interquartile range) age was 60 (51-68) years, and 40% were female. The median tumour size was 4.2 cm and 91.3% had malignant tumours. In all, 27% of the tumours were high stage, 37% high grade, and 63% of the patients underwent partial nephrectomy. There was significant agreement between human and AI scores on linear regression analyses (R ranged from 0.574 to 0.828, all P < 0.001). The AI-generated scores were equivalent or superior to human-generated scores for all examined outcomes including high-grade histology, high-stage tumour, indolent tumour, pathological tumour necrosis, and radical nephrectomy (vs partial nephrectomy) surgical approach. CONCLUSIONS: Fully automated AI-generated C-Index, PADUA, and tumour CSA nephrometry scores are similar to human-generated scores and predict a wide variety of meaningful outcomes. Once validated, our results suggest that AI-generated nephrometry scores could be delivered automatically from a preoperative CT scan to a clinician and patient at the point of care to aid in decision making.

In vitro Comparison of the Mechanical and Optical Characteristics of 5 Disposable Flexible Ureteroscopes.

INTRODUCTION: Disposable (single-use) flexible ureteroscopes are alternatives to reusable ureteroscopes. With their superior surgical efficacy and safety in the presence of upper urinary calculi, disposable ureteroscopes aim to overcome the main limitations of conventional reusable ureteroscopes. However, studies on the performance of the most recently developed models of single-use flexible ureteroscopes are scarce. This study aimed to compare the in vitro performance of several recently introduced, single-use, flexible ureteroscopes. METHODS: Five disposable flexible ureteroscopes were tested in vitro to evaluate their mechanical and optical characteristics. To this end, their degrees of deflection, irrigation flow rates, and image qualities were investigated. The models examined were Innovex US31-B12, OTU-100RR, Redpine RP-U-C12, Sciavita SUV-2A-B, and Seplou URS3016E. Their performance was also compared with that of a reusable flexible ureteroscope, Olympus URV-F. RESULTS: The OTU device had the highest degrees of deflection and the smallest loop diameter of the disposable ureteroscopes. The single-use ureteroscopes had identical image resolutions at a distance of 1 cm. The Innovex and Redpine devices had the best color representation. CONCLUSIONS: Of the tested disposable ureteroscopes, the OTU device had the best mechanical attributes, given its small loop diameter, high deflection angles, and low irrigation flow loss. As to their optical properties, the resolutions of all 5 single-use models were identical at an image distance of 1 cm.

The current role of cytoreductive nephrectomy for metastatic renal cell carcinoma.

The management of metastatic renal cell carcinoma (mRCC) continues to be a therapeutic challenge; however, the options for systemic therapy in this setting have exploded over the past 20 years. From the advent of toxic cytokine therapy to the subsequent discovery of targeted therapy (TT) and immune checkpoint inhibitors, the landscape of viable treatment options continues to progress. With the arrival of cytokine therapy, two randomized trials demonstrated a survival benefit for upfront cytoreductive nephrectomy (CN) plus interferon therapy and this approach became the standard for surgical candidates. However, it was difficult to establish the role and the timing of CN with the subsequent advent of TT, just a few years later. More recently, two randomized phase III studies completed in the TT era questioned the use of CN and brought to light the role of risk stratification while selecting patients for CN. Careful identification of the mRCC patients who are likely to have a rapid progression of the disease is essential, as these patients need prompt systemic therapy. With the continued advancement of systemic therapy using the immune checkpoint inhibitors as a first line therapy, the role of CN will continue to evolve.

Intraoperative and early postoperative complications in postchemotherapy retroperitoneal lymphadenectomy among patients with germ cell tumors using validated grading classifications.

BACKGROUND: Postchemotherapy retroperitoneal lymphadenectomy (PC-RPLND) is an essential, yet potentially morbid, therapy for the management of patients with advanced germ cell tumors. In the current study, the authors sought to define the complication profile of PC-RPLND using validated grading systems for intraoperative adverse events (iAEs) and early postoperative complications. METHODS: Between 2000 and 2018, all patients who underwent PC-RPLND were analyzed for iAEs and early postoperative complications using the Kaafarani and Clavien-Dindo classifications, respectively. Logistic regression models were conducted to assess patient and tumor factors associated with iAEs and postoperative complications. RESULTS: Of the 453 patients identified, 115 patients (25%) and 252 patients (56%), respectively, experienced an iAE and postoperative complication. Major iAEs (grade ≥3) were observed in 15 patients (3%) and major postoperative complications (grade ≥3) were noted in 80 patients (18%). The most common iAE was vascular injury (112 of 132 events; 85%), which occurred in 92 patients (20%), and the most frequent postoperative complication was ileus, which occurred in 121 patients (27%). Original and postchemotherapy retroperitoneal mass size, nonretroperitoneal metastases, intermediate and/or poor International Germ Cell Cancer Collaborative Group classification, previous RPLND, elevated tumor markers at the time of RPLND, and anticipated adjuvant surgical procedures increased the risk of both iAEs and postoperative complications. Patients who experienced an iAE were significantly more likely to experience a postoperative complication (odds ratio, 2.50; 95% confidence interval, 1.58-3.97 [P < .001]). CONCLUSIONS: In what to the authors' knowledge is the first analysis of PC-RPLND using validated classifications for both iAEs and postoperative complications, advanced disease and surgical complexity significantly increased the risks of major iAEs and postoperative complications. Standardized reporting of adverse perioperative events allows providers and patients to appreciate the consequences of PC-RPLND during counseling and decision making.

Compensatory Changes in Parenchymal Mass and Function after Radical Nephrectomy.

PURPOSE: Loss of renal function remains a major limitation of radical nephrectomy. The extent of renal functional compensation by the preserved kidney after radical nephrectomy has not been adequately studied in this elderly population with comorbidities. MATERIALS AND METHODS: A total of 273 patients treated with radical nephrectomy without end stage renal disease with available preoperative nuclear renal scans were included in the analysis. Renal functional compensation was defined as percent change in estimated glomerular filtration rate of the preserved kidney after radical nephrectomy. Estimated glomerular filtration rate was calculated by the Chronic Kidney Disease-Epidemiology Collaboration formula up to 5 years postoperatively. Preoperative/postoperative parenchymal volumes of the preserved kidney were measured from cross-sectional imaging. Multiple regression was used to identify predictive factors for renal functional compensation. RESULTS: Median age was 67 years and 67% of the patients were male. Overall 70% had hypertension, 26% diabetes and 37% preexisting chronic kidney disease. Locally advanced (T3a or greater) tumors were found in 53% of cases. Renal functional compensation was observed at 2 weeks (median 10%) and increased during the first 3 months (median 26%) after radical nephrectomy. Functional stability was then observed to 5 years. Renal parenchymal volume increased a median of 10% at 3 to 12 months but in addition, the functional efficiency per unit of parenchymal volume also increased 8% (estimated glomerular filtration rate units/cm3 of parenchyma was 0.236 postoperatively vs 0.208 preoperatively, p=0.004). Age (-0.85, p <0.01), global preoperative estimated glomerular filtration rate (-0.28, p <0.01) and split renal function of the removed kidney (0.61, p <0.01) were independent predictors of renal functional compensation. CONCLUSIONS: Percent renal functional compensation after radical nephrectomy is greater in younger patients, when preoperative estimated glomerular filtration rate is lower and when the removed kidney has more robust function. Increases in measurable parenchymal mass and functional efficiency contribute substantially to renal functional compensation.

Renal Cancer Surgery in Patients without Preexisting Chronic Kidney Disease-Is There a Survival Benefit for Partial Nephrectomy?

PURPOSE: Retrospective studies suggest that partial nephrectomy provides improved survival compared to radical nephrectomy even when performed electively. However, selection bias may contribute. We evaluated factors associated with nonrenal cancer related mortality after partial and radical nephrectomy in patients with a preoperative glomerular filtration rate of 60 ml/minute/1.73 m2 or greater. MATERIALS AND METHODS: We retrospectively evaluated the records of 3,133 patients with a preoperative glomerular filtration rate of 60 ml/minute/1.73 m2 or greater who underwent partial or radical nephrectomy. Nonrenal cancer related mortality was analyzed by the Kaplan-Meier test based on procedure and functional parameters, including the new baseline glomerular filtration rate. We used the Cox proportional hazards model to assess factors associated with nonrenal cancer related mortality among patients with a new baseline rate of 45 ml/minute/1.73 m2 or greater. RESULTS: Overall median age was 59 years and the median preoperative glomerular filtration rate was 85 ml/minute/1.73 m2. The new baseline glomerular filtration rate was 80 and 63 ml/minute/1.73 m2 and 10-year nonrenal cancer related mortality was 11.3% and 17.7% after partial and radical nephrectomy, respectively (each p <0.001). Median followup was 9.3 years. Nonrenal cancer related mortality was similar in all patients with a new baseline glomerular filtration rate of 45 ml/minute/1.73 m2 or greater (p = 0.26). However, it increased 50% or more in the 290 patients with a new baseline below this level (p = 0.001). In patients with a new baseline greater than 45 ml/minute/1.73 m2 10-year nonrenal cancer related mortality was still substantially improved after partial nephrectomy (10.6% vs 16.3%, p <0.001). In this population age, gender and partial vs radical nephrectomy were associated with nonrenal cancer related mortality on multivariable analysis (all p ≤0.001). In contrast, the increased new baseline glomerular filtration rate, as seen for partial nephrectomy, was not associated with reduced nonrenal cancer related mortality. CONCLUSIONS: In patients with a glomerular filtration rate of 60 ml/minute/1.73 m2 or greater who undergo partial or radical nephrectomy our data suggest that treatment should achieve a new baseline of 45 ml/minute/1.73 m2 or greater if feasible. Partial nephrectomy should be prioritized if needed to accomplish this. In patients with a new baseline rate of 45 ml/minute/1.73 m2 or greater partial nephrectomy was associated with improved survival. However, the functional dividend, namely the increased new baseline rate, failed to correlate, suggesting that selection bias may also impact outcomes.

Can We Predict Functional Outcomes after Partial Nephrectomy?

PURPOSE: The percent of preserved parenchymal mass is the primary determinant of functional outcomes after partial nephrectomy. Accurate methods to predict the percent of preserved parenchymal mass based on preoperative imaging could facilitate patient counseling. MATERIALS AND METHODS: We evaluated the records of 428 patients who had undergone partial nephrectomy and the studies necessary to assess preserved ipsilateral parenchymal mass and function. Preoperative and postoperative ipsilateral parenchymal volumes were measured from contrast enhanced computerized tomography less than 2 months before and 3 to 12 months after partial nephrectomy and the actual percent of preserved parenchymal mass was determined. The ipsilateral percent of preserved parenchymal mass and the final global glomerular filtration rate were estimated based on preoperative imaging using subjective estimation, quantitative estimation, or estimation derived from the contact surface area or the R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior and location relative to polar lines) score. RESULTS: Median tumor diameter was 3.5 cm, median contact surface area was 24 cm2 and the median R.E.N.A.L. score was 8. The median actual ipsilateral percent of preserved parenchymal mass was 84% and the preserved percent of the global glomerular filtration rate was 89%. The median estimated ipsilateral percent of preserved parenchymal mass was 85%, 87%, 88% and 83% based on subjective estimation, quantitative estimation, contact surface area and the R.E.N.A.L. score, respectively. Correlations between the actual and the estimated percent of preserved parenchymal mass were relatively weak in all instances (all r ≤0.46). Prediction of the final global glomerular filtration rate was strong for all 4 methods (all r = 0.91). However, a similarly strong correlation was obtained when presuming that 89% of the preoperative global glomerular filtration rate would be saved in each case (r = 0.91). On multivariable analyses a solitary kidney, the preoperative glomerular filtration rate and various estimates of the percent of preserved parenchymal mass were significantly associated with the final global glomerular filtration rate. However, the preoperative glomerular filtration rate proved to be the strongest predictor. It had more than a tenfold impact compared to the estimated percent of preserved parenchymal mass or a solitary kidney. CONCLUSIONS: Currently available methods to estimate the percent of preserved parenchymal mass have important limitations. The final global glomerular filtration rate, which is the most important functional outcome, could be predicted fairly accurately by all tested methods. However, none of them were better than simply presuming that 89% of function would be saved due to strong anchoring to the preoperative glomerular filtration rate.

Open partial nephrectomy when a non-flank approach is required: indications and outcomes.

PURPOSE: To evaluate indications/outcomes for open partial nephrectomy (OPN) when non-flank approaches are required, with comparison to patients managed with the flank approach. Outcomes with a non-flank approach are presumed less favorable yet there have been no previous reports on this topic. METHODS: 2747 OPNs were performed (1999-2015) and 76 (2.8%) required a non-flank approach. We also reviewed all traditional flank OPNs performed during odd years in this timeframe yielding 1467 patients for comparison. RESULTS: Overall, median tumor size was 3.5 cm and 274 patients (18%) had a solitary kidney. Non-flank patients were younger, and tumor size and clinical/pathologic stage were significantly increased for this cohort, but the groups were otherwise comparable. Indications for non-flank OPN included large tumor size/locally advanced disease (n = 21), need for simultaneous surgery (n = 25), previous flank incision or failed thermoablation (n = 13), or congenital/vascular abnormalities (n = 9). The most common non-flank approach was anterior subcostal (n = 39, 51%). Operative times, estimated blood loss, positive margins, and functional decline were all modestly increased for non-flank patients. Intraoperative and genitourinary complications were more common in non-flank patients (p < 0.05), although all were manageable, typically with conservative measures. There were no mortalities among non-flank patients and none required long-term dialysis. CONCLUSIONS: Our series, the first to address this topic, suggests that outcomes with non-flank OPN are generally less advantageous likely reflecting increased tumor/operative complexity. However, complications in this challenging patient population are manageable and final dispositions are generally favorable. Our findings should be useful for counseling regarding potential outcomes when a non-flank incision is required.

Acute Kidney Injury after Partial Nephrectomy of Solitary Kidneys: Impact on Long-Term Stability of Renal Function.

PURPOSE: Acute kidney injury often leads to chronic kidney disease in the general population. The long-term functional impact of acute kidney injury observed after partial nephrectomy has not been adequately studied. MATERIALS AND METHODS: From 2004 to 2014 necessary studies for analysis were available for 90 solitary kidneys managed by partial nephrectomy. Functional data at 4 time points included preoperative serum creatinine, peak postoperative serum creatinine, new baseline serum creatinine 3 to 12 months postoperatively and long-term followup serum creatinine more than 12 months postoperatively. Adjusted acute kidney injury was defined by the ratio, observed peak postoperative serum creatinine/projected postoperative serum creatinine adjusted for parenchymal mass loss to reveal the true effect of ischemia. The long-term change in renal function (the long-term functional change ratio) was defined as the most recent glomerular filtration rate/the new baseline glomerular filtration rate. The relationship between the grade of the adjusted acute kidney injury and the long-term functional change was assessed by Spearman correlation analysis and multivariable regression. RESULTS: Median patient age was 64 years and median followup was 45 months. Median parenchymal mass preservation was 80%. Adjusted acute kidney injury occurred in 42% of patients, including grade 1 injury in 20 (22%) and grade 2/3 in 18 (20%). On univariable analysis the degree of the adjusted acute kidney injury did not correlate with the long-term glomerular filtration rate change (p = 0.55). On multivariable analysis adjusted acute kidney injury was not associated with a long-term functional change (p >0.05) while diabetes and warm ischemia were modestly associated with a long-term functional decline (each p <0.05). CONCLUSIONS: Acute kidney injury after partial nephrectomy was not a significant or independent predictor of long-term functional decline in our institutional cohort. A prospective study with larger sample sizes and longer followup is required to evaluate factors associated with long-term nephron stability.

Impact of Comorbidities on Functional Recovery from Partial Nephrectomy.

PURPOSE: Parenchymal mass preservation, and ischemia type and/or duration can influence functional recovery after partial nephrectomy. Some groups have hypothesized that relevant comorbidities may also impact nephron stability and functional recovery but this has not been adequately investigated. MATERIALS AND METHODS: At our center 405 patients treated with partial nephrectomy from 2007 to 2015 had the necessary data to determine the function and parenchymal mass preserved in the ipsilateral kidney. Comorbidities potentially associated with renal functional status were reviewed, including various degrees of hypertension, diabetes, cardiovascular disease, obesity, smoking status and related medications. Multivariable linear regression was done to assess factors associated with functional recovery, defined as the percent of preserved ipsilateral glomerular filtration rate. RESULTS: Median tumor size was 3.5 cm and the median R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and tumor touching main renal artery or vein) score was 8. Warm and cold ischemia were done in 264 (65%) and 141 patients for a median duration of 21 and 27 minutes, respectively. The median preserved ipsilateral glomerular filtration rate was 79%. Patient age, comorbidity index, hypertension and proteinuria were each associated with the preoperative glomerular filtration rate (all p <0.01). On univariable and multivariable analyses the preserved parenchymal mass, and ischemia type and duration were significantly associated with functional recovery (all p <0.001). On univariable analysis of comorbidities only hypertension was significantly associated with functional recovery. However, on multivariable analysis none of the analyzed comorbidities were associated with functional recovery. CONCLUSIONS: Recovery of function after partial nephrectomy depends primarily on parenchymal mass preservation and ischemia characteristics. Comorbidities failed to be associated with functional outcomes. Comorbidities can impact function, leading to surgery, and may influence long-term functional stability. However, our data suggest that they do not influence short-term recovery after partial nephrectomy.

Predictors of Long-Term Survival after Renal Cancer Surgery.

PURPOSE: Renal cancer surgery can adversely impact long-term function and survival. We evaluated predictors of chronic kidney disease 5 years and nonrenal cancer mortality 10 years after renal cancer surgery. MATERIALS AND METHODS: We analyzed the records of 4,283 patients who underwent renal cancer surgery from 1997 to 2008. Radical and partial nephrectomy were performed in 46% and 54% of patients, respectively. Cumulative probability ordinal modeling was used to predict chronic kidney disease status 5 years after surgery and multivariable logistic regression was used to predict nonrenal cancer mortality at 10 years. Relevant patient, tumor and functional covariates were incorporated, including the preoperative glomerular filtration rate (A), the new baseline glomerular filtration rate after surgery (B) and the glomerular filtration rate loss related to surgery (C), that is C = A - B. In contrast, partial or radical nephrectomy was not used in the models due to concerns about strong selection bias associated with the choice of procedure. RESULTS: Multivariable modeling established the preoperative glomerular filtration rate and the glomerular filtration rate loss related to surgery as the most important predictors of the development of chronic kidney disease (Spearman ρ = 0.78). Age, gender and race had secondary roles. Significant predictors of 10-year nonrenal cancer mortality were the preoperative glomerular filtration rate, the new baseline glomerular filtration rate, age, diabetes and heart disease (all p <0.05). Multivariable modeling established age and the preoperative glomerular filtration rate as the most important predictors of 10-year nonrenal cancer mortality (c-index 0.71) while the glomerular filtration rate loss related to surgery only changed absolute mortality estimates 1% to 3%. CONCLUSIONS: Glomerular filtration rate loss related to renal cancer surgery, whether due to partial or radical nephrectomy, influences the risk of chronic kidney disease but it may have less impact on survival. In contrast, age and the preoperative glomerular filtration rate, which reflects general health status, are more robust predictors of nonrenal cancer mortality, at least in patients with good preoperative function or mild chronic kidney disease.

Analysis of survival for patients with chronic kidney disease primarily related to renal cancer surgery.

OBJECTIVES: To evaluate predictors of long-term survival for patients with chronic kidney disease primarily due to surgery (CKD-S). Patients with CKD-S have generally good survival that approximates patients who do not have CKD even after renal cancer surgery (RCS), yet there may be heterogeneity within this cohort. PATIENTS AND METHODS: From 1997 to 2008, 4 246 patients underwent RCS at our centre. The median (interquartile range [IQR]) follow-up was 9.4 (7.3-11.0) years. New baseline glomerular filtration rate (GFR) was defined as highest GFR between nadir and 6 weeks after RCS. We retrospectively evaluated three cohorts: no-CKD (new baseline GFR of ≥60 mL/min/1.73 m2 ); CKD-S (new baseline GFR of <60 mL/min/1.73 m2 but preoperative GFR of ≥60 mL/min/1.73 m2 ); and CKD due to medical aetiologies who then require RCS (CKD-M/S, preoperative and new baseline GFR both <60 mL/min/1.73 m2 ). Analysis focused primarily on non-renal cancer-related survival (NRCRS) for the CKD-S cohort. Kaplan-Meier analysis assessed the longitudinal impact of new baseline GFR (45-60 mL/min/1.73 m2 vs <45 mL/min/1.73 m2 ) and Cox regression evaluated relative impact of preoperative GFR, new baseline GFR, and relevant demographics/comorbidities. RESULTS: Of the 4 246 patients who underwent RCS, 931 had CKD-S and 1 113 had CKD-M/S, whilst 2 202 had no-CKD even after RCS. Partial/radical nephrectomy (PN/RN) was performed in 54%/46% of the patients, respectively. For CKD-S, 641 patients had a new baseline GFR of 45-60 mL/min/1.73 m2 and 290 had a new baseline GFR of <45 mL/min/1.73 m2 . Kaplan-Meier analysis showed significantly reduced NRCRS for patients with CKD-S with a GFR of <45 mL/min/1.73 m2 compared to those with no-CKD or CKD-S with a GFR of 45-60 mL/min/1.73 m2 (both P ≤ 0.004), and competing risk analysis confirmed this (P < 0.001). Age, gender, heart disease, and new baseline GFR were all associated independently with NRCRS for patients with CKD-S (all P ≤ 0.02). CONCLUSION: Our data suggest that CKD-S is heterogeneous, and patients with a reduced new baseline GFR have compromised survival, particularly if <45 mL/min/1.73 m2 . Our findings may have implications regarding choice of PN/RN in patients at risk of developing CKD-S.

The Impact of Arterial Clamping Technique in Robot-Assisted Partial Nephrectomy on Renal Function and Surgical Outcomes: Six-Year Experience at Siriraj Hospital, Thailand.

INTRODUCTION: Robot-assisted partial nephrectomy (RAPN) with different arterial clamping techniques has increasingly been performed to avoid ischemic injury to nephron. However, postoperative renal function remains controversial. We determine the impact of each renal arterial clamping on surgical and renal outcomes after RAPN. MATERIALS AND METHODS: Patients who underwent RAPN at Siriraj Hospital from 2010 to 2016 were retrospectively reviewed and stratified into 3 cohorts: main-clamp (MAC), selective-clamp, and off-clamp. RESULTS: Main, selective, and off-clamping were performed in 27, 38, and 12, respectively. Median tumor size and Radius, Exophytic or endophytic, Nearness to collecting system or sinus, Anterior or posterior, and Location relative to polar lines (RENAL) score were 3 cm and 7, respectively. Longer operative time was observed in MAC (p = 0.002) although estimated blood loss, transfusion rate, and complication were comparable. Warm ischemia time was not different between cohorts. However, number of patients with prolonged ischemia time in MAC were greater (p ≤ 0.01). All margins were negative. Median postoperative and latest glomerular filtration rate reduction were 3.8 and 5.3 mL/min/1.73 m2, respectively without significant difference between cohorts. On multivariable analysis, hypertension independently associated with reduced renal function preserved (p = 0.03). Median follow-up was 18 months. CONCLUSIONS: Our study is the first to report surgical and renal functional outcomes after RAPN in Southeast-Asian population. Based on our experience, clamping techniques does not impact on renal functions and complication rate was low even in small-volume center.

Devascularized Parenchymal Mass Associated with Partial Nephrectomy: Predictive Factors and Impact on Functional Recovery.

PURPOSE: Parenchymal mass loss is the predominant factor associated with functional outcomes after partial nephrectomy. It is primarily due to excised and/or devascularized parenchymal mass. We evaluated the importance of excised and devascularized parenchymal mass relative to functional recovery after partial nephrectomy. MATERIALS AND METHODS: In 168 patients who underwent partial nephrectomy the necessary studies were done to determine excised and devascularized parenchymal mass, and evaluate parenchymal mass changes and functional loss of the operated kidney. Parenchymal mass loss in the ipsilateral kidney was measured on contrast enhanced computerized tomography less than 2 months before and 3 to 12 months after partial nephrectomy. Excised parenchymal mass was estimated by subtracting tumor volume from specimen volume. Devascularized parenchymal mass was defined as total parenchymal mass loss minus excised parenchymal mass. We used the Pearson correlation to evaluate relationships between glomerular filtration rate preservation and parenchymal mass loss. Multivariable analysis was done to assess factors associated with devascularized parenchymal mass. RESULTS: Median tumor size was 3.4 cm and median R.E.N.A.L. (radius, exophytic/endophytic tumor properties, nearness of tumor to collecting system or sinus, anterior/posterior and location relative to polar lines) score was 7. Warm and cold ischemia was used in 100 and 68 patients, respectively. Median excised parenchymal and devascularized parenchymal mass was 9 and 16 cm3, respectively (p <0.001). Total parenchymal mass loss and devascularized parenchymal mass were associated strongly with glomerular filtration rate preservation in the operated kidney (each r ≥0.55, p <0.001). However, excised parenchymal mass was only weakly associated with functional outcomes (r = 0.23). The preoperative glomerular filtration rate and endophytic status were associated with devascularized parenchymal mass on multivariable analysis. CONCLUSIONS: To our knowledge we report the first study to specifically evaluate the relative contributions of devascularized and excised parenchymal mass to functional recovery after partial nephrectomy. Our study suggests that devascularized parenchymal mass has more impact, which may have implications regarding surgical technique. Prospective study is required to further evaluate the relative contributions of excised and devascularized parenchymal mass in various settings.

A Case Report of Ruptured Malignant Neuroendocrine Tumor of Kidney, an Extraordinary Presentation.

We report the case of a 51-year-old Thai female presented with right abdominal mass with pain and anemia. The radiographic findings showed ruptured renal mass. She underwent radical nephrectomy and the pathological report was malignant neuroendocrine tumor. Palliative chemotherapy was administered. The patient passed away three months after the operation. Renal neuroendocrine tumors are rare. Moreover, ruptured renal tumors are very rare. They are usually considered to be angiomyolipoma or renal cell carcinoma. Poor differentiation and rupture at presentation are aggressive features of tumors. To the best of our knowledge, this is the first case report of ruptured renal malignant neuroendocrine tumor.

Comparison of renal function of patients after tumor nephrectomy versus donor nephrectomy: Long term outcome using a propensity score matching analysis.

Objective: To compare long-term incidence rate of chronic kidney disease (CKD) in patients after tumor nephrectomy (TN) and donor nephrectomy (DN) and to evaluate risk factors for developing CKD. Materials and methods: Data from 1048 patients who performed TN (552) and DN (496) between 2000 and 2018 at Siriraj hospital were retrospectively analyzed. We obtained 106 patients for each group after using a 1:1 propensity score matching by age and preoperative glomerular filtration rate (GFR). The incidence rate of CKD and risk factors for CKD stage ≥3 were evaluated. Results: There were no differences in incidence of CKD between TN (26.4 %) and DN group (24.5 %) with median follow-up time of 4.95 and 6.05 years (p = 0.308). There were no differences in mean GFR postoperatively at up to ten years follow-up (p = 0.378). The GFR at last follow-up was 71.15 and 68.1 ml/min/1.73 m2 in TN and DN groups (p = 0.172). The TN showed more proteinuria than DN group but not for postoperative hypertension. The multivariate analysis showed age 47 years (p = 0.012) and preoperative GFR 100 (p = 0.001) as a risk factor for developing CKD after nephrectomy but not for type for nephrectomy (p = 0.753). Conclusion: The risk of developing CKD in patients after tumor nephrectomy was the same as in living kidney donors who were matched by age and preoperative GFR. Age over 47 years and preoperative GFR <100 of patients should be considered risk factors for developing CKD in patients choosing nephrectomy as the treatment of choice.

Perioperative factors and 30-day major complications following radical cystectomy: A single-center study in Thailand.

Objective: This study aims to evaluate the prevalence of early postoperative complications of radical cystectomy, using standardized reporting methodology to assess perioperative characteristics and determine risk factors for major complications. Materials and methods: A retrospective study included 254 consecutive bladder cancer patients undergoing RC between 2012 and 2020 at a urological cancer referral center. Postoperative complications within 30 days were recorded and graded according to the Clavien-Dindo classification (CDC). The study examined risk factors, including novel inflammatory-nutrition biomarkers and perioperative serum chloride. Results: Total complications were observed in 135 (53 %). Of these, 47 (18.5 %) were high grade (CDC ≥ 3). Wound dehiscence was the most common complication, occurring in 14 (5.5 %) patients. Independent risk factors for major complications included an age-adjusted Charlson comorbidity index (ACCI) > 4 and thrombocytopenia (odds ratio [OR] 3.67 and OR 8.69). Preoperative platelet counts < 220,000/µL and albumin < 3 mg/dL were independent risk factors for wound dehiscence (OR 3.91 and OR 4.72). Additionally, postoperative hypochloremia was a risk factor for major complications (OR 13.71), while novel serum biomarkers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory response index (SIRI), and prognostic nutritional index (PNI) were not associated with early major complications. Conclusion: Patients who have multiple comorbidities are at a greater risk of developing major complications after undergoing RC. Our result suggests that preoperative platelet counts and serum albumin levels are associated with wound dehiscence.

Survival benefits after radical nephrectomy and IVC thrombectomy of renal cell carcinoma patients with inferior vena cava thrombus.

Objective: The role of tumor thrombus as a predictor of survival in patients with renal cell carcinoma (RCC) is controversial. This study aims to evaluate surgical and oncological outcomes after surgery in RCC with inferior vena cava (IVC) tumor thrombus patients. Materials and methods: A total of 58 patients (2002-2019) underwent radical nephrectomy and IVC thrombectomy at our institute, were retrospectively reviewed. Kaplan-Meier analysis was utilized to compare survival benefits between cohorts and Cox-regression to evaluate potential predictors of patient survival. Results: There were 5(8.6%), 21(36.2%), 23(39.7%) and 9 (15.5%) patients with tumor thrombus level I, II, III and IV respectively. The major complications (Clavien 3-5) were observed in 15 patients (25.8%) and 12 patients (80%) were patients with high thrombus level (III-IV). There was 9%mortality (5patients): 2 intraoperatively and 3 postoperatively. Median follow-up was 15 months (IQR:5-41). Two-year overall survival (OS) was 80% and 75% in all patients and pN0M0 cohort, respectively. There was significant difference in OS among each IVC thrombus level cohort (p < 0.02). Two-year OS of metastatic RCC patients was 67% and not significantly different when compared to non-metastatic cohort (p = 0.12). On multivariate analysis, only sarcomatoid dedifferentiation was associated with OS(p = 0.04). Disease-free survival was not significantly different among thrombus-level cohorts (p = 0.65). Conclusions: Our study suggested that surgical treatment for RCC with IVC thrombus provided substantial OS outcomes. Although survival was significantly reduced with higher IVC thrombus level cohort, the level of thrombus itself was not an independent factor. Only sarcomatoid dedifferentiation was a predictor for reduced OS after radical nephrectomy and tumor thrombectomy. Meticulous patient selection and prompt counselling are substantial step for the operation.

A clinical overview of people living with HIV and genitourinary cancer care.

The number of people living with HIV infection has been increasing globally. Administration of antiretroviral therapy is effective in controlling the infection for most patients and, as a consequence, people living with HIV (PLWH) now often have a long life expectancy. However, their risk of developing cancer - most notably virus-related cancers - has been increasing. To date, few studies have assessed the risk of genitourinary cancers in PLWH, and robust scientific data on their treatment-related outcomes are lacking. Previous studies have noted that PLWH are at a reduced risk of prostate cancer; however, low adoption and/or availability of prostate cancer screening among these patients might be confounding the validity of this finding. In genitourinary cancers, advanced stage at diagnosis and reduced cancer-specific mortality have been reported in PLWH. These data likely reflect, at least in part, the inequity of health care access for PLWH. Notably, systemic chemotherapy and/or radiotherapy could decrease total CD4+ cell counts, which could, therefore, increase the risk of morbidity and mortality from cancer treatments in PLWH. Immune checkpoint inhibitors have become the therapeutic backbone for many advanced malignancies in the general population; however, most studies validating their efficacy have excluded PLWH owing to concerns of severe adverse effects from immune checkpoint inhibitors themselves and/or related to their immunosuppressed status. To our knowledge, no genitourinary cancer survivorship programme exists that specifically caters to the needs of PLWH. By including PLWH in ongoing cancer trials, we can gain invaluable insights that will help to improve cancer care specifically for PLWH.

Testosterone recovery after androgen deprivation therapy.

PURPOSE: Finite courses of androgen deprivation therapy (ADT) are often utilized in men undergoing treatment for prostate cancer. Previous evidence suggests that timing of testosterone (T) recovery can be variable after ADT. Recently, an oral gonadotropin releasing-hormone (GnRH) antagonist, relugolix, has demonstrated more rapid T recovery than injectable GnRH agonists such as leuprolide. In this study, we sought to evaluate patient characteristics associated with T recovery in patients undergoing ADT of defined duration. MATERIALS AND METHODS: The Northwestern Enterprise Data Warehouse was queried for men with prostate cancer who completed a course of ADT and subsequently had a testosterone lab performed. Testosterone recovery was evaluated for levels that reached above castrate (T > 50 ng/dl), partial recovery (T > 150 ng/dl), and full recovery (T ≥ 300 ng/dl). RESULTS: 388 men who received finite courses of ADT were identified (348 receiving leuprolide, 36 receiving relugolix, and 4 receiving degarelix). In multivariable Cox regression analysis, men who were prescribed GnRH antagonists (HR = 3.74, CI = 2.53-5.53, P ≤ 0.001) and who were younger (HR for 1 year increase in age = 0.96, CI = 0.95-0.98, P < 0.001) were more likely to achieve partial recovery. In a subgroup analysis, men who received extended ADT courses (>12 months) with a GnRH agonist had lower rates of partial T recovery (HR = 0.58, CI = 0.41-0.81, P = 0.001). CONCLUSION: T recovery after ADT is variable with roughly one sixth of men remaining castrate. GnRH antagonist use and younger age are associated with higher rates of T recovery after ADT. Longer ADT courses were associated with worse T recovery rates.