The Cumulated Stone Diameter: A Limited Tool for Stone Burden Estimation.

OBJECTIVE: To compare the performance of the main methods used to estimate stone burden in order to improve and standardize preoperative evaluation of stone disease. METHODS: From January 2012 to June 2013, a series of consecutive retrograde intrarenal stone surgery was prospectively evaluated at a single institute. All patients had a pre- and postoperative CT scan. The stone burden was estimated using 3 methods: the cumulative stone diameter (M1), Ackermann's formula (M2), and the sphere formula (M3). The predictive value of the postoperative stone-free status of these methods was then compared. RESULTS: Overall (n = 142), the stone-free rate was 64%. The three methods (M1, M2, and M3) were all predictive of stone-free status for stones <20 mm (P = .0076, .018, and .016, respectively). However, only M2 and M3 were significant for stones >20 mm (P = .0024 and .023). Using receiver operating characteristic curves, we found that areas under the curve were 0.73, 0.70, and 0.71 for stones below 20 mm and 0.53, 0.74, and 0.74 for stones above 20 mm for M1, M2, and M3, respectively. In multivariate analysis, M1 and M3 were both found to be independently associated with the stone-free status in the whole series (P <.001 and .011, respectively). However, for stones above 20 mm, only M3 was significant (P = .020). CONCLUSION: Evaluation of the stone burden is an important predictor of the outcome of retrograde intrarenal stone surgery. For stones below 20 mm, all the three methods approximate stone burden correctly; however, for the stones above 20 mm, calculation of volume is recommended.

Nephron-sparing surgery for renal tumors measuring more than 7 cm: morbidity, and functional and oncological outcomes.

BACKGROUND: The purpose of this study was to evaluate morbidity, functional, and oncological outcomes after NSS in renal tumors > 7 cm. MATERIALS AND METHODS: We retrospectively analyzed data from 168 patients with tumors > 7 cm who were treated using NSS between 1998 and 2012. RESULTS: Imperative and elective indications accounted for 76 (45.2%) and 92 (54.8%) patients, respectively. Major perioperative complications and renal function deterioration occurred in 33 (19.6%) and 51 patients (30.4%), respectively. In multivariate analysis, age older than 60 years (P = .001; hazard ratio [HR], 5) and tumor malignancy (P = .014; HR, 6.7) were prognostic factors for renal function deterioration whereas imperative indication was a risk factor for major postoperative complications (P = .0019; HR, 2.7). In 126 (75%) patients with malignant tumors, after a median follow-up of 30 months (range, 1-254 months), 25 patients (20.2%) died. In multivariate analysis, imperative indication (P = .023; HR, 4.2), positive surgical margin (P = .021; HR, 3.3), and Fuhrman grade > II (P = .013; HR, 3.7) were prognostic indicators for cancer-free survival (CFS). Imperative indication (P = .04; HR, 8.5) and Fuhrman grade > II (P = .04; HR, 3.9) were predictive factors of cancer-specific survival (CSS). In case of elective indication, positive surgical margin, local recurrence, and cancer-related death occurred in 4 (7.6%), 1 (1.1%), and 1 (1.1%) cases, respectively. For elective indication, 5-year estimates of CFS, CSS, and overall survival rates were: 85.7%, 98%, and 93.9%, respectively. CONCLUSION: In this selected population, imperative vs. elective indication status seems to play a critical role in oncologic outcomes. Oncologic results for elective indications are close to those reported with radical nephrectomy.

The oncologic impact of a delay between diagnosis and radical nephroureterectomy due to diagnostic ureteroscopy in upper urinary tract urothelial carcinomas: results from a large collaborative database.

OBJECTIVES: According to the current upper urinary tract urothelial carcinomas (UTUC) guidelines, ureteroscopic evaluation (URS) is recommended to improve diagnostic accuracy and obtain a grade (by biopsy or cytology). However, URS may delay radical surgery [e.g., nephroureterectomy (RNU)]. The objective of this study was to evaluate the influence of URS implementation before RNU on patient survival. METHODS: A French multicentre retrospective study including 512 patients with nonmetastatic UTUC was conducted between 1995 and 2011. Achievement of ureteroscopy (URS), treatment time (time between imaging diagnosis and RNU), tumour location, pT-pN stage, grade, lymphovascular invasion (LVI) and the presence of invaded surgical margins (R+) were evaluated as prognostic factors for survival using univariate and multivariate Cox regression analyses. Cancer-specific survival (CSS), recurrence-free survival (RFS) and metastasis-free survival (MFS) were calculated using the Kaplan-Meier method. RESULTS: A total of 170 patients underwent ureteroscopy prior to RNU (URS+ group), and 342 did not undergo URS (URS-). The median treatment time was significantly longer in the URS+ group (79.5 vs. 44.5 days, p = 0.04). Ureteroscopic evaluation was correlated with ureteral location and lower stage and tumour grade (p = 0.022, 0.005, 0.03, respectively). Tumour stage, LVI+ and R+ status were independently associated with CSS (p = 0.024, 0.049 and 0.006, respectively). The 5-year CSS, RFS and MFS did not differ between the two groups (p = 0.23, 0.89 and 0.35, respectively). These results were confirmed for muscle-invasive (MI) UTUC (p = 0.21, 0.44 and 0.67 for CSS, RFS and MFS, respectively). CONCLUSIONS: Despite the increased time to radical surgery, diagnostic ureteroscopy can be systematically performed for the appraisal of UTUC to refine the therapeutic strategy without significantly affecting oncological outcomes, even for MI lesions.

Influence of positive surgical margin status after radical nephroureterectomy on upper urinary tract urothelial carcinoma survival.

BACKGROUND: The influence of a positive surgical margin (PSM) on survival outcome of post radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UUT-UC) is unclear. The objectives of this study were to determine the significance of PSM on cancer-specific survival (CSS), recurrence-free survival (RFS), and metastasis-free survival (MFS) post RNU. METHODS: From a multicenter collaborative database, data on SM status, stage, grade, lymph node status, lymphovascular invasion (LVI), tumor location, follow-up, and survival was retrieved for 472 patients. Patients underwent open RNU with bladder cuff excision. Clinicopathological features were compared using χ(2) or Fisher exact test and unpaired t test for categorical and continuous variables, respectively. Survival was estimated using the Kaplan-Meier method, and univariate and multivariate Cox proportional hazards regression models were calculated. RESULTS: Median follow-up was 27.5 months (12.1-49.3 months). PSM was identified in 44 patients (9.3%) and correlated with pT stage (p = 0.002), grade (p < 0.001), LVI (p < 0.001), and location (p < 0.001). Univariate analyses revealed that PSM was a poor prognostic factor for CSS, RFS, and MFS (p = 0.003, 0.04, and <0.001, respectively). The 5-yr CSS and MFS for PSM was 59.1 and 51.6%, respectively, compared with 83.3 and 79.3% for patients with negative SM. Multivariate analyses revealed that SM status was an independent predictor of MFS [hazard ratio 2.7; p = 0.001). CONCLUSIONS: PSM after RNU is an important prognostic factor for developing UUT-UC metastases. The status of the surgical margin should be systematically reported on the pathological report and may be a useful variable to include in nomogram risk prediction tools.