Predicting Recurrence After Radical Surgery for High-Risk Renal Cell Carcinoma: Development and Internal Validation of the "TOWARDS" Score.

BACKGROUND: Considering the reported greater benefits of immunotherapy and its unignorable adverse events in adjuvant therapy for high-risk renal cell carcinoma (hrRCC), accurate prediction may optimize drug use. METHODS: The primary objective of this study was to generate a score-based prognostic model of recurrence-free survival in hrRCC. The study retrospectively evaluated 456 patients at two institutions who underwent radical surgery for nonmetastatic pT3-4 and/or N1-2 or pT2 and G4 disease. Clinical variables deemed universally available were selected through backward stepwise analysis and fitted by a multivariable Cox proportional hazards regression model. A point-based score was derived from regression coefficients. Discrimination, calibration, and decision curve analyses were conducted to evaluate predictive performance. Internal validation with bootstrapping was performed to correct for optimism. RESULTS: The mean follow-up period was 55.3 months, and the median follow-up period was 28.0 months. During the follow-up period, the recurrence rate was 48.2% (n = 220) during a median of 75.7 months. Stepwise variable selection retained age, Eastern Cooperative Oncology Group (ECOG) performance status, presence or absence of symptoms, size of the primary tumor, pathologic T stage, pathologic N stage, tumor grade, and histology. Subsequently, the TOWARDS score (range 0-53) was developed from these variables. Internal validation showed an optimism-corrected C-index of 0.723 and a calibration slope of 0.834. The decision curve analysis showed the superiority of this score over the University of California, Los Angeles (UCLA) Integrated Staging System and GRade, Age, Nodes, and Tumor score. CONCLUSIONS: The authors' novel TOWARDS scoring model had good accuracy for predicting disease recurrence in patients with hrRCC, and the clinical practicability was superior to that of the existing models.

Association between lung immune prognostic index and survival of patients with metastatic urothelial carcinoma treated with pembrolizumab.

INTRODUCTION AND OBJECTIVE: Lung immune prognostic index score (LIPI), calculated using the derived neutrophil-lymphocyte ratio and lactate dehydrogenase level, is reported for use in numerous malignancies, while its role on metastatic urothelial carcinoma (mUC) treated with pembrolizumab remains limited. We aimed to investigate association between LIPI and outcomes in this setting. METHODS: We retrospectively evaluated 90 patients with mUC treated with pembrolizumab at four institutions. The associations between three LIPI groups and progression-free survival (PFS), overall survival (OS), objective response rates (ORRs) or disease control rates (DCRs) were assessed. RESULTS: Based on the LIPI, good, intermediate, and poor groups were observed in 41 (45.6%), 33 (36.7%), and 16 (17.8%) patients, respectively. The PFS and OS were significantly correlated with the LIPI (median PFS: 21.2 vs. 7.0 vs. 4.0 months, p = 0.001; OS: 44.3 vs. 15.0 vs. 4.2 months, p < 0.001 in the LIPI good vs. intermediate vs. poor groups). Multivariable analysis further revealed that LIPI good (vs. intermediate or poor, hazard ratio: 0.44, p = 0.004) and performance status = 0 (p = 0.015) were independent predictors of a longer PFS. In addition, LIPI good (hazard ratio: 0.29, p < 0.001) were shown to be associated with a longer OS together with performance status = 0 (p < 0.001). The ORRs tended to be different among patients with Good LIPI compared with Poor, and DCRs were significantly different among the three groups. CONCLUSIONS: LIPI, a simple and convenient score, could be a significant prognostic biomarker of OS, PFS, and DCRs for mUC treated with pembrolizumab.

C-reactive protein kinetics to predict recurrence of high-risk renal cell carcinoma after radical surgery.

BACKGROUND: With new options in adjuvant settings, clinical biomarkers to predict recurrence after radical surgery for high-risk renal cell carcinoma (hrRCC) are in need but are scarcely investigated. We aimed to verify the predictive value of perioperative C-reactive protein (CRP) kinetics on hrRCC recurrence. METHODS: We retrospectively evaluated 154 patients who underwent radical surgery for hrRCC (≥ pT3 and/or N1-2 and M0) at two institutions. Patients were classified into Normal (< 0.5) and High (≥ 0.5) according to their preoperative serum CRP (mg/dL). The High group were further classified into Normalized (< 0.5 at post) or Non-normalized (≥ 0.5 at post), and recurrence-free survival (RFS) was compared between groups. Factors for RFS were further analysed, and Harrell's concordance index (C-index) for the accuracy of predicting RFS was compared with and without the addition of CRP-related variables to pre-existing models. RESULTS: The RFS was significantly shorter in the High (n = 72, 46.8%) compared to the Normal (n = 82, 53.2%) group (9.7 vs. 66.7 months, p < 0.001). Within the High group, Non-normalized (n = 27, 17.5%) patients showed a significantly shorter RFS compared to the Normalized (n = 45, 29.2%) group (6.2 vs. 20.3, p = 0.009). In the multivariable stepwise analysis, CRP kinetics (hazard ratio 2.15, p = 0.029) effectively predicted RFS while baseline CRP fell short of significance. Higher C-index improvement was observed with CRP non-normalization than the baseline value when added to factors in the Karakiewicz and University of California Los Angeles Integrated Staging System models. CONCLUSIONS: CRP kinetics effectively predicted RCC recurrence after surgery and may aid in decision-making for adjuvant systemic therapy.

"Thrombus-first" or "thrombus-last" approach for surgical management of renal cell carcinoma with inferior vena cava thrombus.

OBJECTIVES: To compare the perioperative outcomes between thrombectomy first then nephrectomy ("thrombus-first") and vice-versa ("thrombus-last") approaches for patients with renal cell carcinoma and inferior vena cava thrombus. METHODS: We retrospectively evaluated 130 patients who underwent nephrectomy and thrombectomy at two institutions between 1992 and 2020. The cohort was classified into the thrombus-first and thrombus-last groups according to the techniques used. Outcomes including the operative time, blood loss, and complications, especially the occurrence of intraoperative tumor embolism of pulmonary artery and postoperative pulmonary embolism, were compared. RESULTS: The thrombus-first and thrombus-last groups comprised 48 and 82 patients, respectively. Characteristics such as age, performance status, Charlson Comorbidity Index, renal function, and level of tumour thrombus were comparable between the two groups. Approximately 41% of the patients had distant metastasis. There were four cases (3.1%) of intraoperative tumor embolism, all from the thrombus-last group. Three patients overall (2.3%) experienced pulmonary embolism postoperatively with two in the thrombus-last group (2.4%) and one in the thrombus-first group (2.1%) (P > 0.999). The surgical time (291.0 min vs 369.0 min, P < 0.001) and the blood loss (1323.0 vs 2100.0 mL, P < 0.001) were significantly smaller for the thrombus-first group than for the thrombus-last group. Occurrence of complications was 25.0% and 43.9% in thrombus-first and thrombus-last groups, respectively (P = 0.029), and 8.3% and 23.2% for events graded ≥3 (P = 0.035). CONCLUSION: In surgery for renal cell carcinoma with inferior vena cava thrombus, performing thrombectomy before nephrectomy may serve to lessen complications, blood loss, and surgical time compared to nephrectomy before thrombectomy.

Therapeutic benefit of lymphadenectomy for older patients with urothelial carcinoma of the upper urinary tract: a propensity score matching study.

OBJECTIVES: Regional lymphadenectomy for urothelial carcinoma of the upper urinary tract is sometimes avoided in older patients to reduce surgical burden. We aimed to evaluate the therapeutic impact of lymphadenectomy in older patients undergoing curative therapy for upper urinary tract urothelial carcinoma. METHODS: The patients with urothelial carcinoma of the upper urinary tract older than 75 years at the time of surgery and without lymph node or distant metastasis who underwent curative therapy at two tertiary hospitals between 1994 and 2019 were retrospectively analyzed. Complete-lymphadenectomy was performed as per our protocol. Cancer-specific survival, overall survival and metastasis-free survival after surgery were evaluated between complete-lymphadenectomy and no/incomplete-lymphadenectomy groups before and after 1:1 propensity score matching. RESULTS: The original cohort included 150 patients (median age, 80.71 years), and complete-lymphadenectomy was performed in 42 (28.00%) patients. Patients in complete-lymphadenectomy group were younger and less likely to be aged >80 years (both, P < 0.0001). After matching, 30 patients were allocated to each group and the ages were comparable (78.58 vs. 77.48 years, P = 0.1738). High-grade perioperative complication rates did not differ between groups both before and after matching. Cancer-specific survival, overall survival and metastasis-free survival were significantly longer in the complete-lymphadenectomy group both before and after matching (all, P < 0.05). CONCLUSIONS: This study suggests that complete-lymphadenectomy may provide therapeutic benefits for older patients. The decision to perform complete-lymphadenectomy must be based on the patient's physical condition, rather than his/her chronological age.

Predictive role of γ-glutamyltransferase in patients receiving nivolumab therapy for metastatic renal cell carcinoma.

INTRODUCTION: γ-Glutamyltransferase is reportedly associated with survival in local and metastatic renal cell carcinoma patients; however, its predictive role among patients treated with immune-checkpoint inhibitors are unknown. This study aimed to investigate the role of γ-glutamyltransferase as a predictive marker among metastatic renal cell carcinoma patients undergoing nivolumab therapy. METHODS: We retrospectively evaluated 69 nivolumab-treated metastatic renal cell carcinoma patients upon failure of one or more systematic therapies. Serum γ-glutamyltransferase levels were determined at baseline and 2 months after nivolumab treatment initiation. Patients were classified as high (≥ 49 U/L) and low (< 49 mg/dL) from baseline GGT levels and the outcomes were compared between the two groups. Furthermore, increased (after/baseline ≥ 2) and non-increased (after/baseline < 2) groups were compared. Progression-free survival and overall survival were evaluated after nivolumab initiation. RESULTS: Overall survival was significantly shorter in the high baseline γ-glutamyltransferase group (20.3%) than in the low group (79.7%) (median 2.33 vs not reached [months], p = 0.0051). Progression-free survival and the overall survival were significantly shorter in the increased than in the non-increased group (24.6% and 75.4%, respectively) (median PFS: 4.43 vs 7.23 [months], p = 0.0373/OS: 24.00 vs not reached, p = 0.0467). On multivariate analyses, high baseline γ-glutamyltransferase was an independent factor for overall survival (p = 0.0345) and increased γ-glutamyltransferase was an independent factor for progression-free survival (p = 0.0276) and overall survival (p = 0.0160). CONCLUSIONS: High baseline γ-glutamyltransferase and its early increase are associated with a poor prognosis in metastatic renal cell carcinoma patients receiving nivolumab. Serum γ-glutamyltransferase levels may help predict treatment outcomes.

Surgery for renal cell carcinoma extending to the right atrium in Japanese institutions: Focusing on cardiopulmonary bypass with or without deep hypothermic circulatory arrest.

OBJECTIVES: To evaluate the outcomes of Japanese patients with renal cell carcinoma undergoing surgery for tumor thrombus invading the right atrium. METHODS: We retrospectively evaluated 23 patients who underwent extracorporeal circulation-assisted surgery at two institutions. Perioperative outcomes and survival rates were evaluated and compared between two groups of patients, which were set according to the use or not of deep hypothermic circulatory arrest. Data on systemic treatments were assessed. RESULTS: The median age was 64 years; the majority of patients were fit according to the Charlson Comorbidity Index. Five (21.7%) patients had at least one distant metastasis, and 17 (73.9%) received systemic therapy. A total of 16 (69.6%) patients underwent deep hypothermic circulatory arrest. Baseline characteristics were comparable between groups. Patients who underwent deep hypothermic circulatory arrest had a non-significant reduction in blood loss compared with those who did not undergo this procedure (1866.0 vs 3513.0 mL, P = 0.102). The complication rate, both of any grade (43.8% vs 71.4%, P = 0.215) and grade ≥3 (6.3% vs 28.6%, P = 0.162), tended to be lower in patients who underwent deep hypothermic circulatory arrest. The mean 90-day mortality rate was 8.7%, with no difference among groups (6.3% vs 14.3%, respectively; P = 0.545). The overall median cancer-specific and overall survival were both 64.4 months, and did not differ between groups. CONCLUSIONS: Renal cell carcinoma patients undergoing extracorporeal circulation-assisted surgery and systemic therapy for right atrial tumor thrombus have acceptable long-term survival rates. Outcomes are comparable regardless of the use of deep hypothermic circulatory arrest.

Limited impact of warm ischemic threshold for partial nephrectomy in the robotic surgery era: A propensity score matching study.

OBJECTIVES: To evaluate the association between extended (≥30 min) warm ischemic time and renal function in patients undergoing robot-assisted partial nephrectomy. METHODS: This multi-institutional study retrospectively recruited 1131 patients who underwent robot-assisted partial nephrectomy. Patients were classified into shorter (<30 min; n = 1038) and longer (≥30 min; n = 92) groups based on the ischemic time required, and 1:2 propensity score matching was used to minimize selection bias. The perioperative outcomes, including acute kidney injury and trifecta attainment, and mid/long-term renal function were assessed before and after matching. RESULTS: Patients in the longer group had tumors with a significantly larger diameter and RENAL nephrometry score. The decline in the nadir of the estimated glomerular filtration rate was significantly greater in the longer than the shorter group in the unmatched and matched cohorts (-16.2 vs -5.5%, P < 0.001; 15.5 vs -9.5%, P = 0.003, respectively). A higher incidence of acute kidney injury (9.8 vs 2.6%, P = 0.002) was observed in the longer group before matching, whereas the difference was comparable after matching. Before matching, the decline in estimated glomerular filtration rate at 6 months postoperatively was greater (-8.2 vs -5.1%, P = 0.005) and trifecta attainment was lower (50.0 vs 63.5%, P < 0.001) in the longer group. However, the differences were comparable for both the parameters between the groups in the matched cohort. CONCLUSIONS: While extended warm ischemia during robot-assisted partial nephrectomy can be demanded in case of large and complex tumors, its impact on postoperative renal function is limited.

Prognostic Value of the Lung Immune Prognostic Index on Recurrence after Radical Surgery for High-Risk Renal Cell Carcinoma.

With emerging options in immediate postoperative settings for high-risk renal cell carcinoma (hrRCC), further risk stratification may be relevant for informed decision making. Balancing the benefits and drawbacks of adjuvant immunotherapy is recommended. We aimed to evaluate the effects of the lung immune prognostic index (LIPI) in this setting. This bi-institutional retrospective study recruited 235 patients who underwent radical surgery for hrRCC between 2004 and 2021. LIPI scores were calculated based on the derived neutrophil-to-lymphocyte ratio and lactate dehydrogenase levels. The association between LIPI scores and local or distant recurrence was analyzed, along with other possible clinical factors. The median recurrence-free survival (RFS) period was 36.4 months. Based on the LIPI scores, 119, 91, and 25 patients were allocated to the good, intermediate, and poor groups, respectively. The RFS was significantly correlated with the LIPI scores, and the 36 month survival rates were 67.3, 36.2, and 11.0% in the good, intermediate, and poor groups, respectively. In the multivariate model, the LIPI independently predicted the RFS, along with symptoms at diagnosis, Eastern Cooperative Oncology Group performance status, pT status, pN status, and tumor grade. The C-index of the LIPI in predicting RFS was 0.63, and prediction accuracy improved with the addition of the LIPI to both GRade, Age, Nodes, Tumor, and the UCLA Integrated Staging System. Conclusively, the LIPI can be a significant prognostic biomarker for predicting hrRCC recurrence, particularly for identifying the highest-risk cohort.

Mesna, Doxorubicin, Ifosfamide and Dacarbazine (MAID) Combination Chemotherapy for Retroperitoneal Sarcoma: A Single-center Experience.

BACKGROUND/AIM: There is limited evidence regarding the systemic treatment of retroperitoneal soft-tissue sarcoma, and the current Japanese guidelines fail to make definitive suggestions. Here, we report our experience with combination chemotherapy of mesna, doxorubicin, ifosfamide, and dacarbazine (MAID) in this population. PATIENTS AND METHODS: We retrospectively reviewed the records of eight patients (three male and five female) who received MAID for pathologically diagnosed metastatic unresectable retroperitoneal sarcoma (either leiomyosarcoma or pleomorphic sarcoma) between October 2019 and January 2022. Treatment efficacy, tolerability (need for dose reduction), and safety profiles were evaluated and summarized. RESULTS: At initiation, the median age was 56.0 years, and the body mass index was 20.0 kg/cm2 Six patients had Eastern Cooperative Oncology Group performance status scores of 0. The net clinical benefit was a partial response in three (37.5%) patients, stable disease in four (50.0%), and progressive disease in one (12.5%). During the median 90.8 weeks of follow-up, disease in five patients progressed, resulting in a median progression-free survival of 48.4 weeks, and five deaths occurred, resulting in an overall survival of 95.1 weeks. Commonly observed adverse events were neutropenia (eight patients), anemia (eight patients), and decreased platelet count (seven patients), which led to dose reduction (60-80%) in six patients. CONCLUSION: MAID combination therapy may be an acceptable option for advanced retroperitoneal sarcoma; however, its benefits must be carefully assessed owing to its not insignificant toxicity.

Comparative Analysis of Real-World Efficacy and Safety of Hypoxia-Inducible Factor Prolyl-Hydroxylase Inhibitors in Kidney Transplant Recipients Versus Nontransplant Individuals: A Single-Center Study.

OBJECTIVES: To compare the efficacy and safety of hypoxia-inducible factor prolyl-hydroxylase inhibitors (HIF-PHis), a novel agent for management of anemia in chronic kidney disease (CKD), between transplant recipients and nontransplant individuals. METHODS: A retrospective analysis was conducted on nondialysis-dependent CKD stage 3 to 5 patients treated with the HIF-PHi roxadustat or daprodustat at a single institution. Patients were categorized as kidney transplant recipients (KTRs) and non-KTRs. Efficacy outcomes (hemoglobin and creatinine levels) and safety profiles (rate of adverse events [AEs], descriptions, and discontinuations due to AEs) were assessed 3 months before and 6 months after HIF-PHi initiation within and then between the groups. RESULTS: The study comprised 82 patients (KTR: 43, non-KTR: 39). Median ages significantly differed between the KTR (52.7 years) and non-KTR (82.9 years) groups (P < .001). Roxadustat was predominantly used in the KTR group (88.4%), while daprodustat was used in the non-KTR group (94.9%, P < .001). Both groups exhibited significant increases in Hb levels at 1, 3, and 6 months post-HIF-PHi initiation (P for trend, <.001), with a relative increase in Hb level at 6 months of 16% for KTRs and 13% for non-KTRs. Creatinine levels showed no significant changes over 6 months. Although no difference was observed in drug discontinuation due to AEs, the KTR group experienced a significantly higher rate of thrombotic events (18.6 vs 2.6%, P = .049). CONCLUSIONS: HIF-PHis demonstrate comparable efficacy for managing anemia in CKD, regardless of transplant status. However, heightened vigilance for thrombosis events is necessary during follow-up for KTRs.

Impact of Warm Ischemia on Acute Kidney Injury After Robotic Partial Nephrectomy Stratified by Baseline Kidney Function.

Objectives: To evaluate the differences in baseline chronic kidney disease (CKD) status in correlations between warm ischemic time (WIT) and acute kidney injury (AKI) or acute/chronic renal function change after robot-assisted partial nephrectomy (RAPN). Methods: This study retrospectively recruited 1290 patients from a multi-institutional RAPN database. The patients were grouped into four preoperative CKD categories: CKD Group 1 (CKDG1), CKD Group 2 (CKDG2), CKD Group 3a (CKDG3a), and CKD Group 3b (CKDG3b). The correlation between WIT and the probability of AKI was assessed according to the baseline CKD grade, together with changes in serum creatinine (sCr) at the postoperative maximum and chronic renal function. Results: AKI was not observed in the CKDG1 group. The probability of AKI at WIT = 30 minutes was 5.6% for CKDG2, 8.5% for CKDG3a, and 11.6% for CKDG3b (all p < 0.05). WIT was an independent predictor of AKI occurrence in the multivariate model for these three CKD groups. Significant weak correlations were observed between WIT and sCr change for all four groups, with R2 = 0.22 for CKDG1, R2 = 0.16 for CKDG2, R2 = 0.03 for CKDG3a, and R2 = 0.09 for ≥CKDG3b. For chronic renal function, correlations were significant in CKDG2, CKDG3a, and ≥CKDG3b, yet R2 was considered small in all cases (<0.1). Conclusions: The association between extended WIT and the probability of AKI increased in patients with more severe baseline CKD. The correlation between WIT and renal function was significant, yet clinically modest.

Impact of Body Mass Index on Outcomes in an Asian population of Advanced Renal Cell Carcinoma and Urothelial Carcinoma Treated With Immune Checkpoint Inhibitors.

OBJECTIVES: To clarify the impact of body mass index (BMI) on treatment outcomes including survival, tumor response, and adverse events (AEs) in patients with advanced renal cell carcinoma (RCC) or urothelial carcinoma (UC) treated with immune checkpoint inhibitors (ICIs) in an Asian population. METHODS: We retrospectively evaluated 309 patients with advanced RCC or UC who received ICIs between September 2016 and July 2021. The patients were divided into high- (i.e., ≥25 kg/m2) and low-BMI (<25 kg/m2) groups according to the BMI at the time of treatment initiation. RESULTS: Overall, 57 patients (18.4%) were classified into the high-BMI group. In RCC patients treated with ICIs as first-line therapy or UC treated with pembrolizumab, progression-free survival (PFS) (p = 0.309; p = 0.842), overall survival (OS) (p = 0.701; p = 0.983), and objective response rate (ORR) (p = 0.163; p = 0.553) were comparable between the high- and low-BMI groups. In RCC patients treated with nivolumab monotherapy as later-line therapy, OS (p = 0.101) and ORR (p = 0.102) were comparable, but PFS was significantly longer in the high-BMI group (p = 0.0272). Further, multivariate analysis showed that BMI was not an independent factor of PFS or OS in all the treatment groups (any, p>0.05). As for AE profiles, in nivolumab monotherapy, the rate was significantly higher in the high-BMI group (p = 0.0203), whereas in the other two treatments, the rate was comparable. CONCLUSIONS: BMI was not associated with survival or response rates of advanced RCC or UC patients treated with ICIs in an Asian population. AEs might frequently develop in high-BMI patients with RCC in nivolumab monotherapy.

Effects of remote ischemic preconditioning on renal protection in patients undergoing robot-assisted laparoscopic partial nephrectomy.

We aimed to evaluate the renoprotective effects of remote ischemic preconditioning (RIPC) in patients undergoing robot-assisted laparoscopic partial nephrectomy (RAPN). Data from 59 patients with solitary renal tumors who underwent RAPN with RIPC comprising three cycles of 5-min inflation to 200 mmHg of a blood pressure cuff applied to one lower limb followed by 5-min reperfusion by cuff deflation, from 2018 to 2020 were analyzed. Patients who underwent RAPN for solitary renal tumors without RIPC between 2018 and 2020 were selected as controls. The postoperative estimated glomerular filtration rate (eGFR) at the nadir during hospitalization and the percentage change from baseline were compared using propensity score matching analysis. We performed a sensitivity analysis with imputations for missing postoperative renal function data weighted by the inverse probability of the data being observed. Of the 59 patients with RIPC and 482 patients without RIPC, 53 each were matched based on propensity scores. No significant differences in the postoperative eGFR in mL/min/1.73 m2 at nadir (mean difference 3.8; 95% confidence interval [CI] - 2.8 to 10.4) and its percentage change from baseline (mean difference 4.7; 95% CI - 1.6 to 11.1) were observed between the two groups. Sensitivity analysis also indicated no significant differences. No complications were associated with the RIPC. In conclusion, we found no significant evidence of the protective effect of RIPC against renal dysfunction after RAPN. Further research is required to determine whether specific patient subgroups benefit from RIPC.Trial registration number: UMIN000030305 (December 8, 2017).

Surgical outcomes for older patients with renal cell carcinoma and inferior vena cava thrombus.

OBJECTIVES: To compare the surgical and oncological outcomes of older patients undergoing surgery for renal cell carcinoma (RCC) with a tumor in the inferior vena cava (IVC) and those of younger patients. MATERIALS AND METHODS: We retrospectively evaluated 123 patients who underwent surgery for RCC-IVC at two institutions between 2008 and 2019. We classified them into the ≥70 years and the <70 years group, based on their age during surgery. The patients' perioperative outcomes as well as survival (overall survival [OS] and cancer-specific survival [CSS]) were evaluated and compared before and after 1:1 propensity score matching. Sensitivity analyses were performed at age thresholds of 75 and 80 years. RESULTS: The ≥70 and the <70 groups comprised 43 and 80 patients, respectively. Most patients in the ≥70 group demonstrated an American Society of Anesthesiologists score of 2 or 3. They were more likely to have a statistically insignificant high (≥3) Charlson Comorbidity index score (16.3 vs. 6.3%) and a lower hemoglobin level (10.4 vs. 11.7 g/dL) than the <70 group. Eighteen (41.9%) and 32 (40.0%) patients had at least one distant metastasis at the time of surgery in the ≥70 and <70 group, respectively. The complication rates (any grade and grade ≥3), the length of hospitalization, readmission rates, and mortality were comparable between the groups, both before and after matching (all, non-specific). There was no statistically significant difference in the OS (median 66.6 vs. not reached [N.R.], P = 0.695) or CSS (N.R. vs. N.R., P = 0.605) between the groups before matching. The OS and CSS results were similar and comparable following matching (both, non-specific). Further, OS and CSS were comparable between the ≥75 and <75 groups, and between the ≥80 and <80 age groups, respectively. CONCLUSION: The surgical outcomes of older patients with RCC-IVC were not inferior to those of younger patients. With careful patient selection, surgery can still be a treatment option.

New Longitudinal Component of the RENAL Nephrometry Score for Predicting the Operative Complexity in Transperitoneal Robot-Assisted Partial Nephrectomy.

Background: In transperitoneal robot-assisted partial nephrectomy (RAPN), an L score of 3 points according to the RENAL nephrometry scoring system does not necessarily denote operative complexity. This study aimed to assess the efficacy of the newly defined longitudinal component to analyze the operative complexity of RAPN. Materials and Methods: We retrospectively analyzed transperitoneal RAPNs performed by a single experienced surgeon for renal tumors between 2017 and 2020. L component was defined as L'1 for midlocated tumors, L'2 for >50% below the polar line, and L'3 for >50% above the polar line. Multivariate regression analysis was performed to test associations between prolonged console time and preoperative factors. The perioperative outcomes were compared among the three cohorts of L' components using propensity score matching: L'1 vs L'3 and L'1 vs L'2. Results: A total of 220 cases (L'1: 107, L'2: 65, L'3: 48) were analyzed. The median console time was prolonged (>130 minutes) in 55 patients (median 108, interquartile range: 90-130 minutes). Longitudinal location (L'3 odds ratio [OR]: 2.93, p = 0.01; L'2 OR: 2.32, p = 0.04), high Mayo adhesive probability score (p = 0.001), multiple renal arteries (p = 0.03), and large size (p = 0.04) were significantly associated with prolonged console time. After matching, 26 cases of L'1 and L'3 and 43 cases of L'1 and L'2 were selected. Console time (108 minutes vs 132 minutes, p = 0.017) and warm ischemia time (17 minutes vs 22 minutes, p = 0.03) were significantly longer in L'3 than in L'1. The difference in console time between L'1 and L'2 was not statistically significant (100 minutes vs 111 minutes, p = 0.08). Conclusion: In the new longitudinal assessment, upper location predicted prolonged console time compared with a middle or lower location. The L' component may help preoperatively assess operative complexity.

Urinary Tract Infection in Hemodialysis-Dependent End-Stage Renal Disease Patients.

INTRODUCTION: The aim of this study was to analyze urinalysis findings and urinary bacterial culture in hemodialysis-dependent end-stage renal disease patients. The research goal was to understand the proportion, risk factors, and the causative organisms of urinary tract infection in hemodialysis-dependent end-stage renal disease patients. MATERIALS AND METHODS: Between May 2020 and June 2021, this study included 100 hemodialysis-dependent end-stage renal disease patients (50 male patients and 50 female patients). The urine underwent microscopic examination, pyuria was defined as ≥5 white blood cells per high-power field, and urinary bacterial cultures were conducted for patients with pyuria. Bacteriuria was defined as ≥104 colony-forming units/mL in men and ≥105 colony-forming units/mL in women. Daily urine output was investigated by oral listening. Postvoiding residual urine volume was measured. RESULTS: Fifty-six percent of male patients and 30% of female patients had normosthenuria, 24% of male patients and 38% of female patients had pyuria, and 20% of male patients and 32% of female patients had a urinary tract infection. A comparison of normosthenuria and urinary tract infection revealed no statistically significant difference in age, time on dialysis, daily urine output, and postvoiding residual urine volume. The proportion of female patients among those with normosthenuria was 34.8%, whereas the proportion of female patients among those with UTI was 61.5%. Urinary bacterial cultures showed that the major causative organisms were Escherichia coli (45%; 18/40 cultures) and extended spectrum beta-lactamase-producing Escherichia coli (17.5%; 7/40 cultures). CONCLUSION: The incidence of urinary tract infection was higher in female patients than in male patients. The proportion of resistant bacteria as the causative organisms was high in hemodialysis-dependent end-stage renal disease patients. Urinary bacterial culture should be checked while patients are able to void urine.