The operative safety and oncological outcomes of laparoscopic nephrectomy for T3 renal cell cancer

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy is a well established treatment for localized RCC, where nephron‐sparing approaches are not appropriate. As surgeon and departmental experience grow more extensive tumours will be tackled laparoscopically. However, little is known about the operative safety and oncological outcomes of the laparoscopic approach for locally advanced RCC. The present study describes the largest reported cohort of patients receiving laparoscopic radical nephrectomy for locally advanced RCC. In the context of suitably experienced personnel in an established centre, we have established that this approach is safe from operative, postoperative and oncological standpoints, with comparable data to existing open series.

OBJECTIVE

• ? To determine the operative, postoperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for locally advanced renal cell cancer (RCC), which, as surgeon and departmental experience increases, is being performed more often.

PATIENTS AND METHODS

• ? In total, 94 consecutive patients receiving LRN for pathologically confirmed T3 or T4 RCC at a tertiary referral centre between March 2002 and May 2010 were analyzed.
• ? Preoperative, operative, tumour and postoperative characteristics were evaluated together with recurrence and outcome data.
• ? Survival was estimated using the Kaplan–Meier method. Cox's proportional hazards model was used for multivariate analysis.

RESULTS

• ? In total, 77 patients had LRN with curative intent and 17 patients had LRN with cytoreductive intent.
• ? There were six LRNs (6.4%) that were converted to open procedures.
• ? Overall, there were two (2.1%) Clavien grade IIIa complications, one (1.1%) grade IVa complication and one (1.1%) postoperative death.
• ? Overall median follow‐up was 17.4 months. In total, 22 (28.6%) patients receiving curative LRN developed a recurrence after a median of 13.9 months; 12 (54.5%) patients developed distant metastases, five (22.7%) patients had local recurrences and three (13.6%) patients had transcoelomic spread. Median predicted progression free survival was 48.4 months in patients undergoing LRN with curative intent. Median predicted overall survival was 65.6 months after curative LRN and 15.7 months after cytoreductive LRN.
• ? Multivariate analysis did not reveal any variables influencing recurrence or survival.

CONCLUSIONS

• ? In the context of suitably experienced personnel in an established centre, LRN for locally advanced RCC is safe from an operative and oncological standpoint.
• ? Patients clinically staged as T3 RCC must still be selected carefully for LRN in a multidisciplinary setting.

     

Systematic classification and prediction of complications after nephrectomy in patients with metastatic renal cell carcinoma (RCC)

Study Type – Harm (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Radical nephrectomy for patients with metastatic renal cell carcinoma results in greater rates of morbidity than for those with less advanced disease. This study systematically characterizes complications associated with nephrectomy for metastatic RCC and identifies patient and disease characteristics that are associated with a greater risk of developing complications. Overall complications were relatively frequent, but major complications (grade 3 or greater) were rare. Increasing age and worsening performance status were associated with increased probability of complications. When complications were sustained, patients were less likely to receive systemic therapy in a timely fashion. These observations may influence the timing or patient selection for surgery or systemic therapy.

OBJECTIVE

• ? To evaluate and identify factors predictive for morbidity after radical nephrectomy in patients with metastatic renal cell carcinoma (mRCC).

PATIENTS AND METHODS

• ? We identified patients with mRCC who underwent nephrectomy at Memorial Sloan‐Kettering Cancer Center (MSKCC) between 1989 and 2009.
• ? Postoperative complications were characterised using a modified version of the Clavien‐Dindo classification system.
• ? Patient and disease characteristics, including a previously validated MSKCC risk‐stratification system using calcium, haemoglobin (Hb), lactate dehydrogenase, and Karnofsky Performance Status (KPS), were evaluated as predictors of postoperative complications using univariate and multivariable logistic regression models.
• ? The area under the receiver operating characteristic curve (AUC) was calculated for each model to assess predictive accuracy and corrected for overfit using 10‐fold cross validation.

RESULTS

• ? Over the study period, 195 patients with mRCC underwent nephrectomy; 53 (27%) developed grade ≥2 complications within 8 weeks of surgery.
• ? Pulmonary, thromboembolic events and anaemia requiring transfusion were the most common types of complications after nephrectomy in the metastatic setting.
• ? In univariate analysis, age, low albumin, low KPS, high corrected serum calcium, low serum Hb, and unfavourable MSKCC risk score were predictive of complications.
• ? Patients who sustained postoperative complications were less likely to receive systemic therapy within 56 days (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.12–0.86; P= 0.024).
• ? A multivariable model containing KPS (OR 14.5; 95%CI 4.34–48.6; P < 0.001) and age (OR 1.04; 95%CI 1.01–1.08; P= 0.014) showed the greatest predictive accuracy (corrected AUC 0.72; 95%CI 0.63–0.80) for postoperative complications.

CONCLUSIONS

• ? Postoperative complications after radical nephrectomy in the setting of mRCC are common and occur frequently in older patients and those with worse KPS.
• ? These complications are important because they may delay or deny receipt of subsequent systemic therapy.

     

Prognostic significance of preoperative kidney volume for predicting renal function in renal cell carcinoma patients receiving a radical or partial nephrectomy

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? At present, many studies have been executed to identify predictors for chronic kidney disease or renal insufficiency after radical nephrectomy or partial nephrectomy. We examined whether preoperative kidney volume is a predictor for renal function after radical or partial nephrectomies in RCC patients. To our knowledge, this is the first study to report on the relationship between preoperative kidney volume and changes in renal function in RCC patients who underwent radical nephrectomy or partial nephrectomy performed by one surgeon.

OBJECTIVE

• ? To investigate whether preoperative kidney volume is a prognostic factor for predicting the postoperative glomerular filtration rate (GFR) in renal cell carcinoma (RCC) patients.

PATIENTS AND METHODS

• ? We included 133 patients who underwent radical (n= 83) or partial (n= 50) nephrectomy for RCC.
• ? Kidney parenchymal volume was measured using personal computer‐based software and GFR was estimated before and after surgery at 6 and 12 months.
• ? We evaluated the change in kidney volume after radical and partial nephrectomy and used regression analysis to identify predictors of lower post‐surgical GFR at 12 months.

RESULTS

• ? The mean volume of the normal side kidney for the radical nephrectomy group increased from 142.4 mL to 166.0 mL (17.2%) and 171.5 mL (21.2%) after surgery at 6 and 12 months, respectively.
• ? In the partial nephrectomy group, the volume of the normal side kidney increased from 127.2 mL to 138.8 mL (9.1%) and 140.6 mL (10.9%) after surgery at 6 and 12 months, respectively.
• ? The volume of the operated side kidney decreased from 128.5 mL to 102.3 mL (20.1%) and 101.8 (20.6%) after surgery at 6 and 12 months, respectively.
• ? In the radical nephrectomy group, older age (P < 0.001), preoperative volume of the normal kidney (P= 0.022) and preoperative GFR for the normal side kidney (P= 0.045) were significant predictors of lower post‐surgical GFR at 12 months.
• ? In the partial nephrectomy group, older age (P= 0.001) and preoperative volume for both kidneys (P= 0.037) were significant predictors of lower post‐surgical GFR at 12 months.

CONCLUSION

• ? Preoperative kidney volume is an independent predictor of GFR in RCC patients who underwent radical or partial nephrectomy.

     

The learning curve for reducing complications of robotic-assisted laparoscopic radical prostatectomy by a single surgeon

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Between December 2005 and January 2010, 200 consecutive patients with prostate cancer received RALP performed by a single surgeon. Only one case with Clavien grade II complication due to gouty arthritis. The complication rate was 1%. We suggested that patient with history of gouty arthritis need to prescribe preventive colchicine. OBJECTIVE

• ? To analyse the learning curve for reducing complications of robotic‐assisted laparoscopic radical prostatectomy (RALP) performed by a single surgeon in Taiwan.

PATIENTS AND METHODS

• ? Complication rates were prospectively assessed in 200 consecutive patients undergoing RALP (Group I: cases 1–50; Group II: cases 51–100; Group III: cases 101–150 and Group IV: cases 151–200).
• ? Complications were classified using the Clavien system: grade I: deviation normal postoperative course without treatment; grade II: drug or bedside treatment; grade III: endoscopic or surgical intervention; grade IV: life‐threatening problem; and grade V: death.
• ? Operative parameters and peri‐operative complications were evaluated, including operative and console time, blood loss and transfusion rate, Gleason scores, positive surgical margin (PSM) rate, specimen volume, tumour size, tumour percentage, node positive rate and intra‐ and postoperative complications.

RESULTS

• ? RALP console time was gradually lowered from Group I to Group IV (P < 0.05). Significantly less blood loss occurred after every 50 cases of RALP (Group I 275 mL, Group II 179 mL, Group III 145 mL, Group IV 102 mL, P < 0.001).
• ? Blood transfusion incidence was 8%, 4%, 2% and 0% in Groups I, II, III and IV, respectively.
• ? Complication rates were 18%, 12%, 18% and 0% in Groups I, II, III and IV, respectively.
• ? Major complications (grade III–IV) were 6%, 2%, 4% and 0% in Groups I, II, III and IV, respectively.
• ? Bowel injury occurred in three cases (Group II: 1; Group III: 2); one received intra‐operative repair without sequelae and two received a transient colostomy and later colostomy closure.

CONCLUSIONS

• ? The learning curve for every 50 cases of RALP showed significantly less blood loss and blood transfusion rate.
• ? The learning curve for significantly decreasing complications is 150 cases.

     

Comparison of oncological outcomes of transperitoneal and retroperitoneal laparoscopic radical nephrectomy for the management of clear‐cell renal cell carcinoma: a multi‐institutional study

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Laparoscopic radical nephrectomy (LRN) can be performed by a retroperitoneal approach with similar efficacy compared to the transperitoneal approach. However, the oncological acceptance of LRN has been based on studies which have been carried out primarily by transperitoneal approach, and oncological results of the retroperitoneal approach alone are lacking. Our study confirmed that retroperitoneal laparoscopic radical nephrectomy is oncologically‐equivalent to transperitoneal approach in homogeneous group with the final pathological diagnosis of clear cell RCC.

OBJECTIVE

• ? To investigate the oncological efficacy of retroperitoneal laparoscopic radical nephrectomy (RLRN) compared with transperitoneal laparoscopic radical nephrectomy (TLRN) for the management of clear‐cell renal cell carcinoma (RCC).

PATIENTS AND METHODS

• ? With emphasis on survival and disease recurrence, a retrospective analysis was made of 580 patients who underwent TLRN (472 patients) or RLRN (108 patients) at 23 institutions between January 1997 and December 2007.
• ? Inclusion criteria were clear‐cell RCC, stage pT1 to pT2 without any nodal involvement, and metastasis.
• ? Overall survival and recurrence‐free survival curves were estimated using the Kaplan–Meier method.
• ? To assess the association between the surgical approach and survival outcomes, Cox proportional hazard models were constructed.

RESULTS

• ? The median follow‐up was 30 months in the TLRN group and 35.6 months in the RLRN group. Both groups were comparable regarding age, gender, body mass index (BMI), Fuhrman’s grade, size of tumours and stage.
• ? Kaplan–Meier curves and the log‐rank test showed no significant difference between the TLRN and RLRN groups in 5‐year overall (92.6% vs 94.5%; P = 0.669) and recurrence‐free survival (92.0% vs 96.2%; P = 0.244).
• ? In a Cox regression model with age, gender, Eastern Cooperative Oncology Group performance status, BMI, nuclear grade and T‐stage adjusted variables, no significant difference was found between the two surgical approaches.

CONCLUSION

• ? The present study is the largest oncological analysis for laparoscopic radical nephrectomy (LRN) comparing transperitoneal and retroperitoneal approaches. The data from it provide the objective evidence to suggest similar oncological outcomes for both approaches to LRN.

     

Radical nephrectomy with vena caval thrombectomy: a contemporary experience

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Renal tumours with caval thrombus are relatively rare. Surgical management is the standard of care for lesions of this nature. Small series have been published by other groups, but our understanding of the optimal management continues to evolve. We present the Memorial Sloan‐Kettering Cancer Center series, with a discussion of techniques and complications. Of interest, we include several patients with high‐level caval thrombi which were managed without bypass, supporting previous publications by the group from University of Miami.

OBJECTIVE

• ? To report on the contemporary Memorial Sloan‐Kettering Cancer Center experience with radical nephrectomy and vena caval thrombectomy.

PATIENTS AND METHODS

• ? Patients who underwent radical nephrectomy and vena caval thrombectomy without the use of bypass techniques were retrospectively identified.
• ? Data were collected on intraoperative and pathological findings as well as postoperative complications and oncological outcomes.

RESULTS

• ? In all, 78 patients underwent radical nephrectomy with off‐bypass resection of vena caval thrombus between 1989 and 2009.
• ? The median (interquartile range, IQR) operation duration was 293 (226–370) min, and median (IQR) blood loss was 1300 (750–2500) mL. In all, 10 patients (13%) were confirmed to have intra‐ or supra‐hepatic tumour thrombus (level 3/4), eight of whom required supra‐hepatic control of the inferior vena cava (IVC).
• ? Major (grade 3–5) postoperative complications occurred in 14 (18%), with five postoperative deaths. Disease recurred in 27/62 patients who were considered completely resected at surgery and had adequate follow‐up.
• ? The overall 5‐year survival (95% confidence interval) probability was 48% (35–60%).

CONCLUSIONS

• ? Radical nephrectomy with vena caval thrombectomy is associated with acceptable postoperative morbidity and mortality, and long‐term survival is possible in some patients.
• ? Many level 3/4 thrombi could be safely approached without the use of bypass techniques.

     

Implementation and external validation of preoperative aspects and dimensions used for an anatomical (padua) score for predicting complications in 74 consecutive partial nephrectomies

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Partial nephrectomy (PN) is the gold standard operation for small renal tumours. The decision for or against a PN has been based mostly on preoperative radiological evaluation of the tumour. Three nephrometry scoring systems have been recently proposed for prediction of postoperative complications of PN (RENAL, C‐index and PADUA). We validate externally the accuracy of the PADUA system and suggest for the first time a novel scoring system, based on the original PADUA system, which implements three other significant factors for the postoperative course of a partial.

OBJECTIVE

• ? To externally validate the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification of renal tumours managed by partial nephrectomy (PN).

PATIENTS AND METHODS

• ? Seventy‐four consecutive patients in a single academic tertiary institution underwent open PN.
• ? Incidence of 90‐day complications was stratified by several clinicopathological variables, such as gender, age of the patient, hospital stay, pathology report, tumour characteristics and positive surgical margins. PADUA scores were given to each case.
• ? The severity of complications was also categorized with the Clavien system.

RESULTS

• ? The optimal threshold of PADUA for the prediction of complications was 8 with a sensitivity equal to 90.9% and a specificity equal to 77.8% (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.73–1.00).
• ? Multivariate analysis revealed that that PADUA is an independent predictor for the risk of complications.
• ? Also, PADUA score ≥8 identified a group of patients with almost 20‐fold higher risk of complications (hazard ratio [HR]= 19.82; 95% CI, 1.79–28.35; P= 0.015).
• ? Patients with papillary histology had greater risk for complications than those with clear‐cell tumours (HR = 4.88; 95% CI, 1.34–17.76; P= 0.016).

CONCLUSIONS

• ? The PADUA score is a simple anatomical system that predicts the risk of postoperative complications. This is the first external validation of this system for open PN from a single centre.
• ? The authors believe that PADUA is an efficient tool, since the only variable of the present study that predicted a higher incidence of complications was the histology type, which is determined after surgery.
• ? However, it should be applied to laparoscopic and robot‐assisted series and it could also include the ischaemia time and surgeon experience in the overall scoring to be complete.

     

Limitations of preoperative biopsy in patients with metastatic renal cell carcinoma: comparison to surgical pathology in 405 cases

Study Type – Diagnostic (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Although there have been many investigations of biopsy for small renal masses, there are scant data on the accuracy of biopsy in the setting of metastatic renal cell carcinoma (mRCC). We report a large series of biopsies and compare with nephrectomy pathology in patients with mRCC. The present study highlights the inaccuracy of biopsy in the setting of metastatic disease, which is related to sampling error because of heterogeneity within the tumour and among metastases. These limitations are important to realize when designing trials that depend on pathological findings from biopsy and not nephrectomy. In addition, we found that biopsy of primary tumours were more likely than biopsy of metastatic sites to be diagnostic of RCC. Future studies with multiquadrant biopsies of primary tumours could yield the most accurate pathological results for future studies.

OBJECTIVE

• ? To evaluate the ability of preoperative biopsy to identify high‐risk pathological features by comparing pathology from preoperative metastatic site and primary tumour biopsies with nephrectomy pathology in patients with metastatic renal cell carcinoma (mRCC).

PATIENTS AND METHODS

• ? We reviewed clinical and pathological data from patients who underwent biopsy before cytoreductive nephrectomy for mRCC at MD Anderson Cancer Center (MDACC) from 1991 to 2007.
• ? Percutaneous biopsy techniques included fine‐needle aspiration, core needle biopsy or a combination of both techniques.

RESULTS

• ? The pathology of 405 preoperative biopsies (239 metastatic site, 166 primary tumour) from 378 patients was reviewed at MDACC before cytoreductive nephrectomy.
• ? The biopsy and nephrectomy specimens had the same histological subtype in 96.0% of clear‐cell renal cell carcinomas (RCCs) and 72.7% of non‐clear‐cell RCCs.
• ? Of 76 nephrectomy specimens where sarcomatoid de‐differentiation was identified, only seven (9.2%) were able to be identified from the preoperative biopsy.
• ? In 38.3% of patients, the same Fuhrman grade was identified in both the biopsy and nephrectomy specimens.
• ? A definitive diagnosis of RCC was more likely to be reported in primary tumour biopsies than in metastatic site biopsies. (P < 0.001).

CONCLUSIONS

• ? Preoperative biopsy has limited ability to identify non‐clear‐cell histological subtype, Fuhrman grade or sarcomatoid features.
• ? When surgical pathology is not available, a biopsy obtaining multiple samples from different sites within the primary tumour should be recommended rather than limited metastatic site biopsy to identify patients for clinical trials.

     

Partial nephrectomy for renal masses ≥ 7 cm: technical, oncological and functional outcomes

What's known on the subject? and What does the study add? Partial nephrectomy for the pT1 renal mass has demonstrated acceptable oncological outcomes in addition to improved overall long‐term survival when compared with radical nephrectomy. Previous reports for lesions ≥7 cm have shown mixed data concerning oncological outcomes and technological success. We demonstrate that partial nephrectomy for renal masses ≥7 cm has acceptable oncological, technical, and functional outcomes. As such, partial nephrectomy should be a surgical option when feasible regardless of tumour size. Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To present outcomes for patients with renal masses ≥7 cm in size who are treated with partial nephrectomy (PN) at our institution and to summarize the cumulative published experience.

PATIENTS AND METHODS

• ? We reviewed our prospectively maintained institutional kidney cancer database and identified patients undergoing PN for tumours >7 cm in size.
• ? Technical, oncological and renal functional data were analyzed and compared with the existing published experience of PNs for tumours >7 cm in size.

RESULTS

• ? In total, 46 patients with 49 renal tumours >7 cm in size who underwent PN were identified.
• ? With a median (range) follow‐up of 13.1 (0.2–170.0) months, there were 16 complications, including four (8.2%) blood transfusions and six (12.2%) urinary fistulae.
• ? The 5‐ and 10‐year overall and renal cell carcinoma (RCC)‐specific survivals were 94.5% and 70.9%. There were five (10.9%) patients who had an upward migration in their chronic kidney disease status after PN.
• ? There were six previous series totalling 280 tumours encompassing the published experience of PN for tumours >7 cm in size. The incidence of urinary fistulae and postoperative haemorrhage, respectively, was in the range 3.3–18.8% and 0–3%.
• ? Although oncological outcomes showed cancer‐specific survival in the range 66–97.0%, series matching PN and RN in patients with T2 RCC show equivalency in RCC‐specific and overall survivals. When reported, PN for tumours >7 cm in size was associated with better renal functional preservation.

CONCLUSION

• ? The findings of the present study show that PN can safely be performed in tumours ≥7 cm in size with acceptable technical, oncological and functional outcomes. Further studies are warranted.

     

EXTENDING THE INDICATIONS AND ANATOMICAL LIMITS OF PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: IMPROVED STAGING OR INCREASED MORBIDITY?

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To assess, in a risk/benefit analysis, the additional risk for complications and benefits of extending the indications and anatomical limits of pelvic lymph node dissection (PLND).

PATIENTS AND METHODS

• ? In total, 971 consecutive patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy from 2003–2007.
• ? Before 1 February 2005, patients with a nomogram probability of lymph node invasion (LNI) <2% did not undergo PLND (No PLND group), whereas those with a LNI ≥2% had a PLND limited to the external iliac nodal group (limited PLND group).
• ? After 1 February 2005, all patients underwent a standard PLND including the external iliac, hypogastric and obturator fossa nodal groups (standard PLND group).
• ? The risk parameters were PLND‐related complications and operating time. Complications were graded using a modified Clavien classification. The benefit was the detection of nodal metastases.

RESULTS

• ? In the subgroup of patients with a LNI ≥2%, standard PLND was a superior operation than the limited PLND in detecting nodal metastases (14.3% vs 4.5%, respectively; P = 0.003).
• ? The risk/benefit of standard vs limited PLND would be one additional grade 3 complication per 20 additional patients with nodal metastases. In the subgroup of patients with LNI <2%, three patients (1.0%) had positive nodes after a standard PLND.
• ? The risk/benefit of standard PLND vs no PLND would be one additional grade 3 complication per three or four additional patients with nodal metastasis. The no PLND group was associated with the lowest risk of grade 1, 2 and 3 complications compared to either the limited or standard PLND groups (P < 0.001).

CONCLUSIONS

• ? In patients with LNI ≥2%, standard PLND detects more nodal metastasis. PLND is associated with higher but non‐prohibitive complications rate.
• ? The present study found no evidence that the incidence of complications would be reduced by a limited PLND.

     

Significant impact of age at diagnosis on the prognosis of Japanese patients with pT1 renal cell carcinoma following surgical resection

Study Type – Prognosis (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Several parameters significantly associated with the prognosis of patients with small venal cell carcinoma (RCC) have been reported; however, the outcomes described in such studies are not totally consistent, and the majority of these studies were based on the data from Western populations. Age of diagnosis is a significant predictor of disease recurrence as well as overall survivals in Japanese patients with pT1 RCC following surgical resection; therefore, intensive follow‐up of older patients is necessary even for those with pT1 RCC.

OBJECTIVE

• ? To retrospectively review oncological outcomes following surgical resection in Japanese patients with pT1 renal cell carcinoma (RCC).

PATIENTS AND METHODS

• ? The present study included a total of 832 consecutive Japanese patients who underwent either radical or partial nephrectomy and were subsequently diagnosed as having localized pT1 RCC.
• ? The significance of several clinicopathological factors in their postoperative outcomes was analysed.

RESULTS

• ? The median (range) age of the 832 patients was 66 (31–90) years. Radical and partial nephrectomies were performed for 710 patients (85.3%) and 122 patients (14.7%), respectively. Distribution of pathological stage was pT1a in 582 patients (70.0%) and pT1b in 250 patients (30.0%).
• ? During the observation period (median 44 months, range 3–114 months), postoperative disease recurrence developed in 38 patients (4.6%) and death occurred in 34 (4.1%). The 5‐year recurrence‐free and overall survival rates were 93.6% and 94.1%, respectively.
• ? Of several factors examined, only age at diagnosis was identified as an independent predictor of both postoperative disease recurrence and overall survival in these patients. Furthermore, there were significant differences in the recurrence‐free and overall survivals among patient groups stratified by age at diagnosis.

CONCLUSION

• ? These findings suggest that age at diagnosis is a significant predictor of disease recurrence as well as overall survival in patients with pT1 RCC following surgical resection; therefore, intensive follow‐up of older patients is necessary even for those with pT1 RCC.

     

Utility of the RENAL nephrometry scoring system in the real world: predicting surgeon operative preference and complication risk

Study Type – Prognosis (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? RENAL nephrometry is a quantitative, reproducible scoring system that characterizes RENAL masses and standardizes reporting. Previous work has suggested that the system may be useful in predicting outcomes after partial nephrectomy. This study is the first to correlate RENAL nephrometry score with operative approach or risk of complication in patients undergoing either partial or radical nephrectomy.

OBJECTIVE

• ? To evaluate the utility of the RENAL scoring system in predicting operative approach and risk of complications. The RENAL nephrometry scoring system is designed to allow comparison of renal masses based on the radiological features of (R)adius, (E)xophytic/endophytic, (N)earness to collecting system, (A)nterior/posterior and (L)ocation relative to polar lines.

METHODS

• ? A retrospective review of all patients at a single institution undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for a renal mass between July 2007 and May 2010 was carried out.
• ? Preoperative RENAL score was calculated for each patient. Surgical approach and operative outcomes were then compared with the RENAL score.

RESULTS

• ? In all, 249 patients underwent either RN (158) or PN (91) with average RENAL scores of 8.9 and 6.3, respectively (P < 0.001).
• ? Patients who underwent RN were more likely to have hilar tumours (64% vs 10%, P < 0.001) than patients who underwent PN, but were no more likely to have posteriorly located tumours (50% each).
• ? There were more complications among patients with RN (58%) vs patients with PN (42%, P= 0.02).
• ? RENAL scores were higher in patients with PN who developed complications than in patients with PN who did not develop complications (6.9 vs 6.0, P= 0.02), with no difference noted among patients with RN developing complications (8.9 vs 8.9, P= 0.99).

CONCLUSION

• ? The RENAL system accurately predicted surgeon operative preference and risk of complications for patients undergoing PN.

     

Cytoreductive nephrectomy in the elderly: a population-based cohort from the USA

Study Type – Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? While cytoreductive nephrectomy is associated with a survival benefit in the context of metastatic renal cell carcinoma, the rates of morbidity and perioperative mortality remain non‐negligible. For example, perioperative mortality may be as high as 21% in elderly patients. The study shows that perioperative death amongst the elderly was substantially lower than what was previously reported from a single institutional report. Nonetheless, postoperative adverse outcomes were non‐negligible in elderly patients relative to their younger counterparts. In consequence, these rates should be discussed at informed consent and a rigorous patient selection remains essential.

OBJECTIVE

• ? To examine the rate of perioperative mortality (PM), and other adverse outcomes in ‘elderly’ patients treated with cytoreductive nephrectomy (CNT).

MATERIAL AND METHODS

• ? Patients who underwent CNT for metastatic renal cell carcinoma were abstracted from the Nationwide Inpatient Sample (1998–2007). ‘Elderly’ was defined as ≥75 years, according to previous definition.
• ? Endpoints consisted of PM, intraoperative and postoperative complications, blood transfusions and length of stay.
• ? We adjusted for the effect of elderly status within five separate logistic regression models. Covariates consisted of comorbidity, race, gender, year of surgery and hospital region.

RESULTS

• ? Overall, CNT was performed in 504 (15.3%) elderly patients and in 2796 (84.7%) ‘younger’ patients (<75 years).
• ? The rate of PM was 4.8% in elderly patients vs 1.9% in the younger patients (P < 0.001). Similarly, the rates of blood transfusions (29.8 vs 21.5%), postoperative complications (27.8 vs 22.8%), and prolonged length of stay (≥8 days) were higher in the elderly (45.0 vs 32.0%; all P < 0.001).
• ? In multivariable analyses, elderly patients were 2.2‐, 1.5‐, and 1.6fold more likely to experience PM, to receive a blood transfusion and to be hospitalized ≥8 days than the younger patients.

CONCLUSIONS

• ? Although the rate of PM was substantially lower than 21%, elderly patients are significantly more likely to die after this type of surgery, to receive a transfusion, and to experience a prolonged length of stay.
• ? These facts and figures should be discussed at informed consent and a rigorous patient selection is essential.

     

Laparoscopic partial nephrectomy: beyond the straightforward T1a

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Complex tumour features (e.g. size, hilar location, multifocality) are generally considered contraindicative for LPN and only a handful of studies reporting encouraging outcomes with more complex tumours. Herein we suggest that in experience hands the benefits of minimally‐invasive surgery may be safely extended to patients with more complex renal masses.

OBJECTIVE

• ? To report on our experience in extending the indications for LPN beyond the single, T1a renal mass assessing the perioperative outcomes in a comparative fashion.

PATIENTS AND METHODS

• ? Retrospective review of consecutive patients undergoing LPN for a renal mass in an academic centre between 2005–2010.
• ? 150 patients were divided into two groups based on tumours characteristics: straightforward T1a (group 1: single, <4 cm, n = 84) and complex (group 2: multiple and/or hilar and/or ≥4 cm, n = 66).
• ? Comparison of demographic, clinical, radiographic and perioperative outcomes (operative times, blood loss, warm ischemia times, intra‐ and postoperative complications).

RESULTS

• ? In group 2, 19 tumours were hilar, 15 were multifocal and 44 measured ≥4 cm; 2 of these criteria were present in 7, and all three in 3 cases.
• ? Warm ischemia times and blood loss were comparable (medians of 21 vs 20 min, and 100 vs 100 mL).
• ? Operative times were longer in group 2 (190 vs 140min, P < 0.001).
• ? Complications occurred in 11.9% and 12.1% of patients in group 1 and 2, with Clavien grade 3 events in 8.3 and 10.9%, respectively (P = 1.00 and P = 0.547).
• ? There were 4 conversions to laparoscopic radical nephrectomy (1 in group 1, 3 in group 2).

CONCLUSION

• ? With adequate laparoscopic expertise, the indications for LPN can be safely extended beyond the single, small, peripheral T1a renal mass. In this series, more complex masses were effectively treated with LPN combining the advantages of minimally‐invasive surgery to those of nephron‐sparing approach.

     

Population‐based comparative effectiveness of nephron‐sparing surgery vs ablation for small renal masses

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Case series of patients undergoing various forms of ablation show that it is technically feasible and possible for ablation to achieve short‐ and intermediate‐term cancer‐specific survival rates similar to those of controls undergoing partial nephrectomy. This is the first well‐powered study with a controlled design to compare effectiveness between partial nephrectomy and ablation.

OBJECTIVE

• ? To determine, in a population‐based cohort, if disease‐specific survival (DSS) was equivalent in patients undergoing ablation vs nephron‐sparing surgery (NSS) for clinical stage T1a renal cell carcinoma (RCC).

PATIENTS AND METHODS

• ? A retrospective cohort study was performed using patients from the Surveillance, Epidemiology and End Results cancer registry with RCC < 4 cm and no evidence of distant metastases, who underwent ablation or NSS.
• ? Kaplan–Meier and Cox regression analyses were performed to determine if treatment type was independently associated with DSS.

RESULTS

• ? Between 1998 and 2007, a total of 8818 incident cases of RCC were treated with either NSS (7704) or ablation (1114).
• ? The median (interquartile range) follow‐up was 2.8 (1.2–4.7) years in the NSS group and 1.6 (0.7–2.9) years in the ablation group, although 10% of each cohort were followed up beyond 5 years.
• ? After multivariable adjustment, ablation was associated with a twofold greater risk of kidney cancer death than NSS (hazard ratio 1.9, 95% confidence interval 1.1–3.3, P= 0.02).
• ? Age, gender, marital status and tumour size were also significantly associated with outcome.
• ? The predicted probability of DSS at 5 years was 98.3% with NSS and 96.6% with ablation.

CONCLUSION

• ? After controlling for age, gender, marital status and tumour size, the typical patient presenting with clinical stage T1a RCC, who undergoes ablation rather than NSS, has a twofold increase in the risk of kidney cancer death; however, at 5 years the absolute difference is small, and may only be realized by patients with long life expectancies.

     

Early infectious complications with transponder placement for external beam radiation therapy for prostate cancer

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Little has been published related to transponders per se, but a number of studies relating to prostate biopsy‐related infections and the increased incidence of quinolone‐resistant Escherichia coli have been published. The study alerts the practising urologist to the risk of quinolone‐resistant E. coli in the setting of transrectally placed transponders. Furthermore, it proposes an antibiotic regimen that should reduce this risk.

OBJECTIVE

• ? To report our series of early infectious complications after placement of Calypso® transponders (Calypso Medical, Seattle, WA, USA) into the prostate.

PATIENTS AND METHODS

• ? Between February 2008 and October 2010, 50 consecutive patients underwent placement of Calypso® transponders into the prostate.
• ? Patients were administered ciprofloxacin 500 mg every 12 h, starting the night before the procedure and for 2 days after the procedure.
• ? Data were collected via chart review, and complications were classified according to the Clavien classification system.

RESULTS

• ? Of the 50 patients undergoing the procedure, five (10%) developed infectious complications, and three (6%) developed a grade II complication with a UTI requiring antibiotic therapy. One patient (2%) developed a grade IIIb complication with an epidural abscess and osteomyelitis of the lumbar vertebrae requiring open debridement and a lumbar fusion. One patient (2%) developed a prostatic abscess with methicillin‐resistant Staphylococcus aureus and subsequently died of an unrelated lower GI bleed.
• ? In 4/50 patients (8%), a culture confirmed the responsible bacteria, of which three cases were quinolone‐resistant Escherichia coli.

CONCLUSION

• ? As with prostate biopsy, the emergence of quinolone‐resistant E. coli remains a challenging infectious complication with transrectal prostate procedures. We propose an alternative strategy of double antibiotic coverage with one dose of oral ciprofloxacin 500 mg and gentamicin 80 mg i.m. before this procedure.

     

Unclassified renal cell carcinoma: a report of 56 cases

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Unclassified RCC represents 0.7–5.7% of renal tumours. Limited reported data from two series suggests that unclassified RCC is an aggressive form of RCC, mainly because most cases are at an advanced stage at presentation, but overall and cancer‐specific survival were not significantly different between unclassified and clear‐cell RCC in an additional series of 38 patients. Our study of 56 cases of unclassified RCC describes the pathological features that can be applied to predict prognosis on a daily basis. In particular nuclear grade, TNM classification, tumour coagulative necrosis, tumour size, microvascular invasion and 2004 WHO histotype are independent predictors of disease‐free and cancer‐specific survival.

OBJECTIVE

• ? To evaluate the clinicopathological features and outcomes of 56 patients with unclassified renal cell carcinoma (RCC) meeting 2004 World Health Organization diagnostic criteria.

PATIENTS AND METHODS

• ? Urological pathology files of the participating institutions were reviewed and cases of unclassified RCC that met the inclusion criteria were retrieved.
• ? Nuclear grade, pT status, tumour size, regional lymph node involvement, distant metastases, coagulative tumour necrosis, mucin and sarcomatoid differentiation were evaluated in radical nephrectomy or nephron‐sparing specimens.
• ? Significant factors in univariate analysis were then assessed by a multivariate analysis of independent prognostic factors using Cox proportional hazard regression analysis.

RESULTS

• ? Fifty‐six cases met the histological criteria for unclassified RCC. Thirty‐four (61%) cases were categorized as unrecognizable cell type (mean overall survival 47 months; median 36 months), 20 (36%) as composites of recognized types (mean overall survival 36 months; median 26 months), and two (4%) (mean survival 16 months; median 16 months) as pure sarcomatoid morphology without recognizable epithelial elements.
• ? Cox multivariate analysis showed nuclear grade (P= 0.020), stage (P < 0.001), tumour coagulative necrosis (P= 0.018), tumour size (P < 0.001), microvascular invasion (P < 0.001) and tumour histotype (P= 0.028) to be independent predictors of disease‐free survival, with tumour size being the most significant (hazard ratio [HR] 9.068, 95% confidence interval [CI] 3.231–25.453).
• ? Nuclear grade (P= 0.026), stage (P < 0.001), tumour coagulative necrosis (P < 0.001), tumour size (P= 0.044), microvascular invasion (P < 0.001), tumour recurrence after surgery (P < 0.001) and tumour histotype (P= 0.056) were independent predictors of cancer‐specific survival, with tumour recurrence after surgery being the most significant (HR 14.713, 95% CI 5.329–40.622).

CONCLUSION

• ? The prognosis of patients with unclassified RCC seems to be related to clinicopathological features known to be relevant in common forms of RCC.

     

Inpatient safety trends in laparoscopic and open nephrectomy for renal tumours

Study Type – Cohort study Level of Evidence 2b What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy for renal cancer provides equivalent long‐term cancer control with shorter hospital stays, less postoperative pain, and faster resumption of normal activities, but it has diffused slowly into clinical practice, perhaps as a result of perceptions about safety. Patient safety outcomes for laparoscopic and open radical nephrectomy using validated measures remain incompletely characterized. This is the first study to investigate peri‐operative outcomes of radical nephrectomy using validated patient safety measures. We found a 32% decreased probability of adverse patient safety events occurring in laparoscopic compared with open radical nephrectomy. The safety benefits of laparoscopy were attained only after 10% of cases were completed laparoscopically – a proportion some have proposed as the ‘tipping point’ for the adoption of surgical innovations. This observation could have implications for patient safety in the setting of diffusion of new surgical techniques.

OBJECTIVE

• ? To compare peri‐operative adverse patient safety events occurring in laparoscopic radical nephrectomy (LRN) with those occurring in open radical nephrectomy (ORN).

METHODS

• ? We used the US Nationwide Inpatient Sample to identify patients undergoing kidney surgery for renal tumours from 1998 to 2008.
• ? We used patient safety indicators (PSIs), which are validated measures of preventable adverse outcomes, and multivariate regression to analyse associations of surgery type with patient safety.

RESULTS

• ? Open radical nephrectomy accounted for 235 098 (89%) cases while 28 609 (11%) cases were LRN.
• ? Compared with ORN, LRN patients were more likely to be male (P= 0.048), have lower Charlson comorbidity scores (P < 0.001), and to undergo surgery at urban (P < 0.001) and teaching (P < 0.001) hospitals.
• ? PSIs occurred in 18 714 (8%) of ORN and 1434 (5%) of LRN cases (P < 0.001).
• ? On multivariate analysis, LRN was associated with a 32% decreased probability of any PSI (adjusted odds ratio 0.68, 95% confidence interval: 0.6 to 0.77, P < 0.001). Stratification by year showed that this difference was initially manifested in 2003, when the proportion of LRN cases first exceeded 10%.

CONCLUSIONS

• ? We found that LRN was associated with substantially superior peri‐operative patient safety outcomes compared with ORN, but only after the national prevalence of LRN exceeded 10%.
• ? Further study is needed to explain these patterns and promote the safe diffusion of novel surgical therapies into broad practice.

     

Management of severe blunt renal trauma in adult patients: a 10-year retrospective review from an emergency hospital

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Immediate surgery for major renal trauma has led to a high rate of nephrectomy in comparison with an expectant management. We reviewed our case material on the management of severe blunt renal trauma in adults with emphasis on conservative management. Only shattered kidneys and pedicle avulsion required immediate surgery.

OBJECTIVE

• ? To review retrospectively the management of major blunt renal truma in adult patients admitted to our level I trauma centre.

PATIENTS AND METHODS

• ? Among 1460 blunt abdominal trauma cases collected from January 2001 to December 2010, 221 (15%) affected the kidneys.
• ? All patients, except seven who needed immediate laparotomy, underwent a computed tomography scan to stage the injuries.
• ? Renal injuries were graded according to the American Association for the Surgery of Trauma Grading System; grade 4 and 5 injuries were subclassified based on vascular or parenchymal injury.

RESULTS

• ? Only 45/221 patients (20%) suffered major blunt renal trauma (21 grade 3, 18 grade 4 and six grade 5); 43% of the patients had associated lesions and 77% had gross haematuria.
• ? Nephrectomy rates were 9% for grade 3, 22% for grade 4 and 83% for grade 5 with an exploration rate of 26% for major renal trauma.

CONCLUSIONS

• ? Conservative management of grade 3–5 blunt renal trauma in haemodynamically stable patients yields more favourable results with high renal salvage rate.
• ? Grade 5 injuries still result in a nephrectomy rate of more than 80%.
• ? The absence of data on long‐term outcomes and a potential inclusion bias due to the retrospective nature of the data represent major limitations of this review.