Management of local recurrence after radical nephrectomy: surgical removal with or without systemic treatment is still the gold standard. Results from a multicenter international cohort.

OBJECTIVE: To evaluate the survival outcomes of patients with local recurrence after radical nephrectomy (RN) and to test the effect of surgery, as monotherapy or in combination with systemic treatment, on cancer-specific mortality (CSM). METHODS: Patients with local recurrence after RN were abstracted from an international dataset. The primary outcome was CSM. Cox's proportional hazard models tested the main predictors of CSM. Kaplan-Meier method estimates the 3-year survival rates. RESULTS: Overall, 96 patients were included. Of these, 44 (45.8%) were metastatic at the time of recurrence. The median time to recurrence after RN was 14.5 months. The 3-year cancer-specific survival rates after local recurrence were 92.3% (± 7.4%) for those who were treated with surgery and systemic therapy, 63.2% (± 13.2%) for those who only underwent surgery, 22.7% (± 0.9%) for those who only received systemic therapy and 20.5% (± 10.4%) for those who received no treatment (p < 0.001). Receiving only medical treatment (HR: 5.40, 95% CI 2.06-14.15, p = 0.001) or no treatment (HR: 5.63, 95% CI 2.21-14.92, p = 0.001) were both independently associated with higher CSM rates, even after multivariable adjustment. Following surgical treatment of local recurrence 8 (16.0%) patients reported complications, and 2/8 were graded as Clavien-Dindo ≥ 3. CONCLUSIONS: Surgical treatment of local recurrence after RN, when feasible, should be offered to patients. Moreover, its association with a systemic treatment seems to warrantee adjunctive advantages in terms of survival, even in the presence of metastases.

Active surveillance in renal tumors: Clinical and oncological outcomes.

CONTEXT: Some patients diagnosed with small renal solid masses or complex cystic lesions may benefit from active surveillance (AS) instead of immediate treatment. AIMS: Report our series of patients undergoing AS for small renal solid and complex cystic lesions, and compare growth rates and outcomes between both types of lesions. MATERIALS AND METHODS: A retrospective review AS database for renal lesions was conducted. From 1995 to 2017, a total of 82 patients with 89 renal lesions were included. We describe our AS protocol, patient and tumor characteristics, comparisons between solid and cystic lesions, and final outcome of patients who underwent delayed intervention (DI). STATISTICAL ANALYSIS USED: Categorical and continuous data were analyzed by the Chi-square and the Student's t-test, respectively. The Wilcoxon/Kruskal-Wallis test was used for growth rate comparisons of solid and complex cystic lesions. RESULTS: Median age of patients at the beginning of AS was 77-year-old, median size for solid and cystic lesions was 2.3 cm (0.08-3.8) and 2.6 cm (1.2-4.0), respectively. No differences in annual growth rate between solid and complex cystic lesions (0.04 cm [0.00-1.5] and 0.05 cm [0.01-1.7]) were observed at a similar median follow-up of 61 months for both groups (range: 15-182, and 14-254). Five patients with solid lesions underwent DI, 3 for rapid growth (>0.5 cm/year), 1 demanded treatment, and 1 due to hematuria. Adherence to AS protocol was high (94%). No cancer-related deaths or metastatic progression was observed, six patients died of another medical condition, being cardiovascular disease the most frequent cause. CONCLUSIONS: AS is a reasonable and safe option for the management of small renal masses. No difference was observed in the growth rate between solid and complex cystic lesions during AS. Centers offering AS should present a standardized protocol and give exhaustive information to patients regarding benefits and risks.

Invasive management of renal cell carcinoma in von Hippel-Lindau disease.

INTRODUCTION: Patients affected by von Hippel-Lindau (VHL) disease experience an increased risk for bilateral, synchronous, and metachronous renal cell carcinoma (RCC). Oncologic and functional outcomes are the main goals in the management of renal masses. We present our protocol for patients with VHL disease-associated RCC alongside functional and oncologic results observed in our series. MATERIAL AND METHODS: We performed a retrospective analysis of our clinical database of patients with VHL disease-associated RCC referred to our department between June 2005 and December 2017. We offer surveillance for lesions <2 cm and active management with radiofrequency ablation (RFA) for lesions 2-3 cm, and nephron-sparing surgery (NSS), RFA or embolization techniques for lesions >3 cm or growth rate >1 cm/year. RESULTS: Our series comprises 14 patients, of whom 13 had undergone at least one invasive procedure for RCC, mean age at first intervention was 27 years (range 18-60). Overall, 30 interventions were performed in 21 kidneys: four radical nephrectomies, 13 RFAs, 12 NSSs, and one embolization. During follow-up (median time: 41 months, range: 6-149), eight patients (57%) presented with new lesions that required treatment, with a mean time between treatments of 32 ±18.5 months. No metastatic progression or need for dialysis was recorded; the success rate for RFA was 85%. CONCLUSIONS: Management of VHL kidney disease by NSS is the standard of care with a cut-off at 3 cm, ablative procedures should be offered to lesions ranging 2-3 cm in size. Follow-up should be done strictly in referral centers that can provide all treatment options to renal function and control oncologic progression.

The role of hemostatic agents in preventing complications in laparoscopic partial nephrectomy.

INTRODUCTION: Nephron-sparing surgery is currently the treatment of choice for renal cell carcinoma stage T1a. During the past years, several hemostatic agents (HA) have been developed in order to reduce surgical complications. We present the results of our series and the impact of the use of HA in the prevention of surgical complications in laparoscopic partial nephrectomies (LPNs). MATERIAL AND METHODS: We retrospectively analyzed all LPN performed in our center from 2005 to 2012. A total of 77 patients were included for analysis. Patients were divided into two groups: Group A (no use of HA) and Group B (use of HA). HA used included gelatin matrix thrombin (FloSeal) and oxidized regenerated cellulose (Surgicel). Demographics, perioperative variables, and complications were analyzed with a special interest in postoperative bleeding and urinary leakage. RESULTS: Median age was 57.17 years old (±12.1), 72.7% were male, most common comorbidities were hypertension (33.8%) and diabetes mellitus (18.2%). All patients had one solitary tumor, and 87% had a tumor ≤4 cm. Renal cell carcinoma was found in 79.2% of cases, and 78.7% were stage pT1a. and were used in 36 cases (46.8%). No differences were found in demographics, perioperative variables, and complications between groups. No conversions to open surgery or perioperative mortality were reported. CONCLUSIONS: We conclude that in our series the use of a hemostatic agent did not offer benefit in reducing the complication rate over sutures over a bolster.