Survival after partial and radical nephrectomy for the treatment of stage T1bN0M0 renal cell carcinoma (RCC) in the USA: a propensity scoring approach

Study Type – Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Partial nephrectomy has become the standard of care for T1a renal tumours, and the application of nephron‐sparing techniques has increasingly been expanded to patients with localized T1b cancers. However, the relative efficacy of partial versus radical nephrectomy for these medium‐sized tumours has yet to be definitively established. This study employs a propensity scoring approach within a large US population‐based cohort to determine that no survival differences exist among patients with T1b renal tumours undergoing partial versus radical nephrectomy.

OBJECTIVES

• ? To compare survival after partial nephrectomy (PN) vs radical nephrectomy (RN) among patients with stage TIb renal cell carcinoma (RCC) using a propensity scoring approach.
• ? Propensity score analysis is a statistical methodology that controls for non‐random assignment of patients in observational studies.

PATIENTS AND METHODS

• ? Using the Surveillance, Epidemiology, and End Results registry, 11 256 cases of RCCs of 4–7 cm that underwent PN or RN between 1998 and 2007 were identified.
• ? Propensity score analysis was used to adjust for potential differences in baseline characteristics between patients in the two treatment groups.
• ? Overall survival (OS) and cancer‐specific survival (CSS) of patients undergoing PN vs RN was compared in stratified and adjusted analysis, controlling for propensity scores.

RESULTS

• ? In all, 1047 (9.3%) patients underwent PN. For the entire cohort, no difference in survival was found in patients treated with PN as compared with RN, as shown by the adjusted hazard ratio (HR) for OS (1.10; 95% confidence interval [CI]: 0.91–1.36) and renal‐CSS (HR 0.91; 95% CI: 0.65–1.27).
• ? When the cohort was stratified by tumour size and age, no difference in survival was identified between the groups.

CONCLUSIONS

• ? Even when stratified by tumour size and age, a survival difference between PN and RN in a propensity‐adjusted cohort of patients with T1b RCC could not be confirmed.
• ? If validated in prospective studies, PN may become the preferred treatment for T1b renal tumours in centres experienced with nephron‐sparing surgery.

     

Elective partial nephrectomy is equivalent to radical nephrectomy in patients with clinical T1 renal cell carcinoma: results of a retrospective, comparative, multi-institutional study

Study Type – Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Few studies supported the expanded indications for nephron‐sparing surgery (NSS) in selected patients with 4.1 cm renal tumours in the size range (T1b). However, all these comparative studies included both imperative and elective partial nephrectomy and patient selection for analysis was based on pathological stage (pT1) and not on clinical stage (cT1). Patients with clinically organ‐confined RCC (cT1) who are candidates for elective PN have a limited risk of clinical understaging. NSS is not associated with an increased risk of recurrence and cancer‐specific mortality both in cT1a and cT1b tumours

OBJECTIVE

• ? To compare the oncological outcomes of patients who underwent elective partial nephrectomy (PN) or radical nephrectomy (RN) for clinically organ‐confined renal masses ≤7 cm in size (cT1).

PATIENTS AND METHODS

• ? The records of 3480 patients with cT1N0M0 disease were extracted from a multi‐institutional database and analyzed retrospectively.

RESULTS

• ? In patients who underwent PN, the risk of clinical understaging was 3.2% in cT1a cases and 10.6% in cT1b cases.
• ? With regard to the cT1a patients, the 5‐ and 10‐year cancer‐specific survival (CSS) estimates were 94.7% and 90.4%, respectively, after RN and 96.1% and 94.9%, respectively, after PN (log‐rank test: P = 0.01).
• ? With regard to cT1b patients, the 5‐year CSS probabilities were 92.6% after RN and 90% after PN, respectively (log‐rank test: P = 0.89).
• ? Surgical treatment failed to be an independent predictor of CSS on multivariable analysis, both for cT1a and cT1b patients.
• ? Interestingly, PN was oncologically equivalent to RN also in patients with pT3a tumours (log‐rank test: P = 0.91).

CONCLUSIONS

• ? Elective PN is not associated with an increased risk of recurrence and cancer‐specific mortality in both cT1a and cT1b tumours.
• ? Data from the present study strongly support the use of partial nephrectomy in patients with clinically T1 tumours, according to the current recommendations of the international guidelines.

     

Nephrectomy improves survival in patients with invasion of adjacent viscera and absence of nodal metastases (stage T4N0 renal cell carcinoma)

OBJECTIVE

To examine the cancer‐specific mortality (CSM) of patients with T4N0–2M0 renal cell carcinoma (RCC) treated with either nephrectomy (RN) or no surgery (NS).

PATIENTS AND METHODS

Of 43 143 patients with RCC identified in the Surveillance, Epidemiology and End Results database, 310 had tumours involving adjacent organs with no evidence of distant metastases (T4NanyM0) and had RN (246, 79.4%) or NS (64, 20.6%). Kaplan‐Meier analyses, Cox regression and competing‐risks regression models were used to compare the effect of RN vs NS on CSS.

RESULTS

In patients with T4N0 disease the median survival benefit associated with RN vs NS was 42 months (48 vs 6 months, P < 0.001). Conversely, the median survival in patients T4N1‐2 was no different between RN and NS (9.3 vs 9.1 months, P = 0.9). Multivariable analyses in T4N0 cases indicated a substantial survival disadvantage for patients having NS vs RN (hazard ratio 4.8, P < 0.001). Conversely, in patients with N1‐2 stages, the CSS was virtually the same for NS and RN (hazard ratio 0.9, P = 0.9). Competing‐risks regression models confirmed the benefit of RC in patients with T4N0 and the lack of benefit in those with T4N1‐2 disease, after controlling for other‐cause mortality.

CONCLUSION

Our data suggest a survival benefit in patients with T4N0 RCC treated with RC. By contrast, RN seems to have no effect on survival in patients with evidence of nodal metastases.     

A comparison of overall survival and perioperative outcomes between partial and radical nephrectomy for cT1b and cT2 renal cell carcinoma—Analysis of a national cancer registry

Objectives

Partial nephrectomy (PN) is the standard management of cT1a renal cell carcinoma (RCC), and there is a basis for expanding its indications to larger tumors (cT1b and cT2). We analyzed a large population-based cancer registry to compare the overall survival (OS) and perioperative outcomes in patients with cT1b and cT2 RCC undergoing PN with those undergoing radical nephrectomy (RN).

Postoperative renal function after partial nephrectomy for renal cell carcinoma in patients with pre‐existing chronic kidney disease: A comparison with radical nephrectomy

We assessed whether adequately functioning parenchyma is preserved in patients with pre‐existing chronic kidney disease (CKD) after partial nephrectomy (PN) compared with those who underwent radical nephrectomy (RN). A total of 95 patients with pre‐existing CKD who underwent curative surgery for pathological T1a‐T2N0M0 renal cell carcinoma with a follow‐up period of 12 months or more were the subject of the present study. Of these, 51 patients underwent RN, and 44 PN. Renal function was assessed by using the estimated glomerular filtration rate (e‐GFR). We classified the subjects into two groups according to the preoperative e‐GFR: preoperative e‐GFR 45–59 mL/min/1.73 m² (68 patients); and 30–44 mL/min/1.73 m² (27 patients). In the former group, the probability of freedom from new onset of e‐GFR <45 mL/min/1.73 m² stemmed from the significant difference between the PN and RN groups (P = 0.006; PN: 2 years 64%; RN: 2 years 22%). In contrast, in the latter group, the probability of freedom from new onset of e‐GFR <30 mL/min/1.73 m² was not associated with a significant difference between PN and RN group (P = 0.80). Overall survival and the number of the patients who went on to develop end‐stage renal disease requiring renal replacement therapy between PN and RN were not significantly different in each group. Death from renal cell carcinoma was not noted in either group. PN could significantly prevent development to late‐stage CKD in patients with preoperative e‐GFR 45–59 mL/min/1.73 m² compared with RN. Patients with preoperative e‐GFR 30–44 mL/min/1.73 m² should be reviewed in a more strict study.     

Baseline renal function,ischaemia time and blood loss predict the rate of renal failure after partial nephrectomy

OBJECTIVE

To identify independent predictors of renal failure after partial nephrectomy (PN) in patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

Data were available for 166 patients with pathological T1‐3 N0M0 RCC treated with PN. Renal failure after PN was defined as a decrease in glomerular filtration rate (GFR) of >25% (RIFLE criteria). The GFR before and after PN was estimated using the Modification of Diet in Renal Disease study group equation. Univariable and multivariable logistic regression models were used to assess a decrease of >25% in GFR from the preoperative level. Candidate predictor variables were age, gender, PN indication (absolute vs relative), preoperative GFR, tumour size, perioperative blood loss, surgery duration and clamping time.

RESULTS

After PN, 22 (13.3%) patients had a decrease in GFR of >25%. The perioperative blood loss (P = 0.02), clamping time (P = 0.04) and preoperative GFR (P = 0.002) were independent predictors of a decrease in GFR of >25%.

CONCLUSIONS

We identified two important potentially modifiable variables that should be considered in the planning of PN, i.e. the clamping time and blood loss. It is possible that selective referral to experienced surgeons who can perform PN within short surgical and clamping times, and with minimal blood loss, could minimize the rate of renal failure, especially in patients with an underlying renal function impairment.     

Nephrectomy improves the survival of patients with locally advanced renal cell carcinoma

OBJECTIVES

To examine the cancer‐specific survival of patients treated with nephrectomy and compared it to that of patients managed without surgery.

PATIENTS AND METHODS

Of 43 143 patients with renal cell carcinoma (RCC) identified in the 1988–2004 Surveillance, Epidemiology and End Results database, 7068 had locally advanced RCC and with no distant metastasis. These patients had a nephrectomy (6786, 96.0%) or no surgical therapy (282, 4.0%). Multivariable Cox regression models, and matched and unmatched Kaplan‐Meier survival analyses, were used to compare the effect of nephrectomy vs non‐surgical therapy on cancer‐specific survival. Also, competing‐risks regression models adjusted for the effect of other‐cause mortality. Covariates and matching variables consisted of age, gender, tumour size and year of diagnosis.

RESULTS

The 1‐, 2‐, 5‐ and 10‐year cancer‐specific survival of patients who had nephrectomy was 88.9%, 88.1%, 68.6% and 57.5%, vs 44.8%, 30.6%, 14.5% and 10.6% for non‐surgical therapy. In multivariable analyses, relative to nephrectomy, non‐surgical therapy was associated with a 5.8‐fold higher rate of cancer‐specific mortality (P < 0.001). Non‐surgical therapy was also associated with a 5.1‐fold higher rate of cancer‐specific mortality in matched analyses (P < 0.001). Finally, competing‐risks regression confirmed the statistical significance of the variable defining treatment type (nephrectomy vs non‐surgical therapy) in multivariable and matched analyses (P < 0.001).

CONCLUSION

Relative to non‐surgical treatment, nephrectomy improves the cancer‐specific survival of patients with locally advanced RCC; our findings await prospective confirmation.     

Comparison of hilar clamping and non-hilar clamping partial nephrectomy for tumours involving a solitary kidney

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? It has been long recognized that ischemic injury to the kidney occurs when the blood supply to the kidney is interrupted by clamping of the renal artery (warm and cold ischemia). We developed a new technique of non‐clamping, non‐ischemic partial nephrectomy with this in mind. This article looks at the results of clamping vs non‐clamping partial nephrectomies in solitary kidneys, where the impact of ischemic injury is most accurately reflected. The technique of non‐ischemic partial nephrectomy accounts for 33% better preservation of renal function, when compared to ischemic partial nephrectomy. This new technique should be used in patients with a solitary kidney, patients with bilateral tumours, and patients with already impaired renal function.

OBJECTIVE

? To compare outcomes of hilar clamping and non‐hilar clamping partial nephrectomy for tumours involving a solitary functional kidney.

patientS AND METHODS

? Between 1990 and 2009, 104 partial nephrectomies, excluding bench and autotransplant procedures, were performed on solitary functional kidneys. ? An institutional review board‐approved retrospective review was performed analyzing patient demographics, operative data, complications, oncological outcomes and estimated glomerular filtration rate (GFR). ? GFR was calculated using the abbreviated Modification of Diet in Renal Disease equation. ? Preoperative GFR was compared to Early GFR (lowest measured GFR 7–100 days postoperatively) and to Late GFR (GFR 101–365 days postoperatively). ? Multiple linear regression analysis was performed to assess covariates affecting Late GFR. ? Kaplan–Meier estimator was utilized to compare renal cell carcinoma (RCC) specific survival and non‐RCC‐related survival.

RESULTS

? In total, 29 partial nephrectomies with hilar clamping and 75 partial nephrectomies without hilar clamping were performed in solitary kidneys. Median follow‐up was 57 months. ? There was no difference in tumour size, location and the number of tumours resected between the two groups. Mean ischaemia time for the clamping group was 25 min. ? Some 97% of the clamping procedures were performed with cold ischaemia. ? There was no difference in intra‐operative estimated blood loss, transfusion requirement or length of hospital stay. ? The complication rate and spectrum of complications were similar between the two groups. ? The two groups had similar preoperative GFR and Early GFR. The non‐clamping group had a significantly smaller percent decrease in Late GFR (11.8% vs 27.7%, P= 0.01) than the clamping group. ? The non‐clamping group was significantly more likely to have a less than 10% decrease in Late GFR compared to the clamping group (60.9% vs 17.7%, P= 0.002). ? On multivariate analysis, only hilar clamping was significantly associated with decreased Late GFR (estimate 15.0, P= 0.02). ? Surgical margin positivity rate was higher in the clamping group (21% vs 4%, P= 0.01); however, the local recurrence rate between the two groups was similar. ? The clamping and non‐clamping groups had similar 5‐year RCC‐specific survival and 5‐year non‐RCC‐related survival.

CONCLUSIONS

? Partial nephrectomy without hilar clamping in solitary kidneys provides similar cancer control compared to partial nephrectomy with hilar clamping. ? Partial nephrectomy without clamping was associated with superior preservation of Late GFR. ? No difference was detected in GFR early after surgery, possibly indicating that there may be ongoing renal loss after hilar clamping.     

Active surveillance of small renal masses offers short‐term oncological efficacy equivalent to radical and partial nephrectomy

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Active surveillance of small renal masses has traditionally been reserved for elderly patients deemed unfit for surgery or ablation. There is increasing evidence showing the safety of active surveillance in the management of small renal masses. In this retrospective study we compared outcomes for patients with small renal masses managed with active surveillance, radical nephrectomy and partial nephrectomy. We showed that active surveillance was safe and appeared as effective as immediate surgery in the management of small renal tumours.

OBJECTIVE

• ? To compare the oncological outcomes of active surveillance (AS), radical nephrectomy (RN) and partial nephrectomy (PN) in the management of T1a small renal masses (SRMs).

PATIENTS AND METHODS

• ? At present AS is used in the treatment of SRMs in elderly patients with multiple co‐morbidities or in those who decline surgery.
• ? We identified all patients with T1a SRMs managed with RN, PN or AS.
• ? Retrospective data were collected from patient case records with survival data and cause of death cross‐referenced with the Oxford Cancer Intelligence Unit.

RESULTS

• ? A total of 202 patients with 234 T1a SRMs (solid or Bosniak IV) were identified; 71 patients were managed with AS, 41 with an RN and 90 by PN.
• ? Over a median follow‐up of 34 months the mean growth rate on AS was 0.21 cm/year with 53% of SRMs managed with AS showing negative or zero growth.
• ? No statistically significant difference was observed in overall (OS) and cancer‐specific (CSS) survival for AS, RN and PN (AS‐CSS 98.6%, AS‐OS 83%; RN‐CSS 92.6%, RN‐OS 80.4%; PN‐CSS 96.6%, PN‐OS 90.0%).

CONCLUSIONS

• ? Active surveillance of SRMs offers oncological efficacy equivalent to surgery in the short/intermediate term.
• ? The results of this study support a multicentre prospective randomized controlled trial designed to compare the oncological efficacy of AS and surgery.

     

Management of Localized Kidney Cancer: Calculating Cancer-specific Mortality and Competing Risks of Death for Surgery and Nonsurgical Management

Background

For elderly individuals with localized renal cell carcinoma (RCC), surgical intervention remains the primary treatment option but may not benefit patients with limited life expectancy.

Objective

To calculate the trade-offs between surgical excision and nonsurgical management (NSM) with respect to competing causes of mortality.

Design, setting, and participants

Relying on a cohort of Medicare beneficiaries, all patients with nonmetastatic node-negative T1 RCC between 1988 and 2005 were abstracted.

Intervention

All patients were treated with partial nephrectomy (PN), radical nephrectomy (RN), or NSM.

Outcome measurements and statistical analysis

Cancer-specific mortality (CSM) and other-cause mortality (OCM) rates were modeled through competing-risks regression methodologies. Instrumental variable analysis was used to account for the potential biases associated with measured and unmeasured confounders.

Results and limitations

A total of 10 595 patients were identified. In instrumental variable analysis, patients treated with PN (hazard ratio [HR]: 0.45; 95% confidence interval [CI], 0.24–0.83; p = 0.01) or RN (HR: 0.58; 95% CI, 0.35–0.96; p = 0.03) had a significantly lower risk of CSM than those treated with NSM. In subanalyses restricted to patients ≥75 yr, the instrumental variable analysis failed to detect any statistically significant difference between PN (HR: 0.48; p = 0.1) or RN (HR: 0.57; p = 0.1) relative to NSM with respect to CSM. Similar trends were observed in T1a RCC only.

Conclusions

PN or RN is associated with a reduction of CSM among older patients diagnosed with localized RCC, compared with NSM. The same benefit failed to reach statistical significance among patients ≥75 yr. The harms of surgery need to be weighed against the marginal survival benefit for some patients.     

Long-term outcomes after radical or partial nephrectomy for T1a renal cell carcinoma: A population-based study

IntroductionThe benefit of partial nephrectomy (PN) compared to radical nephrectomy (RN) for T1a renal cell carcinoma (RCC) remains uncertain, with observational studies conflicting with level 1 evidence. Therefore, the purpose of this population-based study was to compare long-term outcomes in patients undergoing PN or RN for T1a RCC.MethodsWe studied 5670 patients in Ontario, Canada undergoing PN or RN for T1a RCC. The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS), chronic kidney disease (CKD), renal replacement therapy, and myocardial infarction (MI). We used multivariable Cox proportional hazard models to evaluate the association between PN or RN and these outcomes. A sensitivity analysis was performed in patients with a preoperative serum creatinine available.ResultsMedian followup was 77 months. Compared to RN, PN was associated with significantly improved OS (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.63–0.84), reduced risk of CKD (HR 0.18, 95% CI 0.12–0.27), and improved CSS (HR 0.45, 95% CI 0.30–0.65). The risk of MI was not significantly different between groups (HR 0.91, 95% CI 0.62–1.34). Few patients (n=15) required renal replacement therapy. In the sensitivity analysis, the association between type of surgery and OS and CKD persisted, while the association with CSS did not.ConclusionsOur study found that in patients undergoing surgery for T1a RCC, PN was associated with improved OS and reduced risk of CKD compared to RN. However, few patients in either group required renal replacement therapy.     

Machine-learning approach for prediction of pT3a upstaging and outcomes of localized renal cell carcinoma (UroCCR-15)

Objectives

To assess the impact of pathological upstaging from clinically localized to locally advanced pT3a on survival in patients with renal cell carcinoma (RCC), as well as the oncological safety of various surgical approaches in this setting, and to develop a machine-learning-based, contemporary, clinically relevant model for individual preoperative prediction of pT3a upstaging.

Materials and Methods

Clinical data from patients treated with either partial nephrectomy (PN) or radical nephrectomy (RN) for cT1/cT2a RCC from 2000 to 2019, included in the French multi-institutional kidney cancer database UroCCR, were retrospectively analysed. Seven machine-learning algorithms were applied to the cohort after a training/testing split to develop a predictive model for upstaging to pT3a. Survival curves for disease-free survival (DFS) and overall survival (OS) rates were compared between PN and RN after G-computation for pT3a tumours.

Results

A total of 4395 patients were included, among whom 667 patients (15%, 337 PN and 330 RN) had a pT3a-upstaged RCC. The UroCCR-15 predictive model presented an area under the receiver-operating characteristic curve of 0.77. Survival analysis after adjustment for confounders showed no difference in DFS or OS for PN vs RN in pT3a tumours (DFS: hazard ratio [HR] 1.08, P = 0.7; OS: HR 1.03, P > 0.9).

Conclusions

Our study shows that machine-learning technology can play a useful role in the evaluation and prognosis of upstaged RCC. In the context of incidental upstaging, PN does not compromise oncological outcomes, even for large tumour sizes.     

Incidence of T3a up-staging and survival after partial nephrectomy: Size-stratified rates and implications for prognosis

Background

The use of partial nephrectomy (PN) to treat renal cell carcinoma has grown to include larger, more complex tumors. Such tumors are more likely to be up-staged to pT3a and generate controversy regarding the oncologic safety of PN. We aimed to estimate the proportion of patients up-staged to T3a disease after PN, stratified by clinical stage, and characterize their survival.

Renal surgery in the elderly: morbidity in patients aged >75 years in a contemporary series

OBJECTIVES

To evaluate the surgical complications in a contemporary group of elderly patients with renal masses, as almost a quarter of patients with newly diagnosed renal mass are aged >74 years, with the potential for significant comorbidity.

PATIENTS AND METHODS

From April 2004 to June 2007, of 379 surgical resections of renal tumours, we assessed 117 consecutive patients aged ≥75 years, who had either radical nephrectomy (RN) or partial nephrectomy (PN) for assumed renal cell carcinoma. Also elderly patients who had nephroureterectomy (NU) for upper urothelial cancer were followed.

RESULTS

Fifty patients had RN, 57 PN and 10 had NU; the median (range) age of all patients was 78.1 (72.7–92.5) years and was similar in all groups. No patient died during surgery and only one died within 90 days. The complication rates during and after surgery RN, PN and NU were 12%, 15% and 20%, respectively; the major complications within 30 days were 4%, 7% and 10%; major complications included bleeding during surgery and one acute bleeding event after surgery in the PN group.

CONCLUSIONS

Open renal surgery in elderly patients can be done safely; there was no difference in morbidity among RN, PN and NU. Renal surgery in the elderly patient is safe if done at a specialized centre. Mortality and morbidity can be very low, rendering this a feasible approach in the treatment of renal masses even if the prognosis is not determined by the oncological situation but by comorbidity.     

Analysis of renal cell carcinoma with subdiaphragmatic macroscopic venous invasion (T3b)

OBJECTIVE

To review our institutional experience of surgery for renal cell carcinoma (RCC) with subdiaphragmatic macroscopic venous invasion (T3b) and to assess variables associated with cancer‐specific survival (CSS), as the stratification of RCC with venous involvement (T3b and T3c) is subject to debate.

PATIENTS AND METHODS

We retrospectively reviewed the hospital records of patients who underwent a radical nephrectomy with resection of subdiaphragmatic tumour thrombus (T T) between October 1990 and May 2006. The log‐rank and Cox uni‐ and multivariate regression analysis were used to evaluate predictive factors for CSS.

RESULTS

In all, 101 cases were identified. In the N0M0 group, univariate Cox regression analysis confirmed that ipsilateral adrenal gland invasion, Mayo Clinic level of T T, histological subtype and fat invasion were significantly associated with worse CSS. In multivariate Cox regression analysis, only Mayo Clinic level of T T was an independent predictor for CSS. In the subgroup with renal vein involvement only, the median CSS was not reached. In the subgroups with level I, II and III T T involvement, the median CSS was 69, 26 and 21 months, respectively. In the N+ and/or M+ group, only tumour size and type were independent predictors of CSS, while the level of T T was not. Radical nephrectomy yielded poor results with a median CSS of 13 months.

CONCLUSION

The Mayo Clinic level of T T is an independent prognostic predictor for CSS in non‐metastatic T3b RCC. We strongly support the need for re‐classification of the currently applied 2002 Tumour‐Node‐Metastasis staging system, which in its present form does not discriminate between levels of subdiaphragmatic venous invasion.     

Radiofrequency ablation of small renal cortical tumours in healthy adults: renal function preservation and intermediate oncological outcome

OBJECTIVES

To present the glomerular filtration rate (GFR) and oncological outcomes in a series of patients with cT1a renal cortical tumours treated with radiofrequency ablation (RFA), a non‐ischaemic minimally invasive ablative method, as nephron‐sparing surgery gives excellent oncological outcomes and preserves renal function.

PATIENTS AND METHODS

Healthy (American Society of Anesthesiologists, ASA, I and II) patients with cT1a renal masses were identified, and clinical and radiographic data were reviewed to assess indications, complications, radiological evidence of disease recurrence, and renal function. Changes in GFR were calculated. Radiological recurrence was defined as any new enhancement (>10 Hounsfield units) after absence of enhancement on initial 6‐week computed tomography.

RESULTS

Four patients were ASA I and 59 were ASA II; the median (range) age was 58 (20–84.6) years and the lesion diameter 2.1 (1–4.0) cm. Preoperative needle biopsy was diagnostic in 89% of patients, including 75% diagnostic of renal cell carcinoma (RCC). At a median (range) follow‐up of 34 (1.0–80) months the renal preservation rate was 97%. One patient had a nephrectomy for biopsy‐confirmed recurrence of RCC at 55 months; a second had a nephrectomy at 24 months for suspected radiographic recurrence, but had no evidence of disease on final pathology. A fifth (20%) of the patients had chronic kidney disease at the time of diagnosis. The median GFR before and after RFA was 76.3 and 74.3 mL/min/m² (difference 2.0 mL/min/m²).

CONCLUSION

RFA might be a reasonable treatment choice for the healthy patient, with appropriate informed consent. Intermediate results suggest excellent oncological outcomes and preservation of renal function.     

Capsular involvement in patients undergoing partial nephrectomy for localized renal cell carcinoma: an adverse pathological finding?

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

OBJECTIVE

To evaluate the prognostic impact of capsular involvement (CaI) in patients treated exclusively with partial nephrectomy (PN) for localized renal cell carcinoma (RCC), as in these patients CaI was recently reported as an adverse prognostic factor.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients treated with PN for a sporadic and localized RCC (pT1‐pT2N0M0) in our institution between 1985 and 2005. Univariate and multivariate analysis using a Cox proportional‐hazards regression analysis were conducted to identify significant predictors of oncological outcome for several clinical and pathological factors, i.e. imperative indication, histological type, Fuhrman grade, tumour size, T stage, CaI, and surgical margins. Disease‐free and ‐specific survival rates of patients with CaI and no evidence of CaI were compared using the log‐rank test.

RESULTS

In all, 305 patients had a PN for localized RCC, of whom 22 (7.2%) had CaI in the PN specimen. The median (range) follow‐up was 6 (1.5–23) years. Multivariate statistical analysis showed that imperative indication for PN and high‐grade RCC were independently associated with worse disease‐free and ‐specific survival, whereas CaI had no prognostic value. Disease‐free and ‐specific survival in patients with and without CaI were not significantly different at 5 and 10 years.

CONCLUSIONS

In a contemporary series of patients exclusively treated with PN for localized RCC, CaI was not predictive of disease recurrence and disease‐specific mortality. These results do not support the use of any change in postoperative management in patients with CaI after PN.     

A comparative population‐based analysis of the rate of partial vs radical nephrectomy for clinically localized renal cell carcinoma

Study Type – Prevalence (prospective cohort with good follow up)Level of Evidence 1a

OBJECTIVE

To examine contemporary (1989–2004) trends in partial nephrectomy (PN) within the Surveillance, Epidemiology and End Results (SEER) database, as among other considerations, a survival benefit due to avoidance of surgically induced renal insufficiency distinguishes PN from radical nephrectomy (RN).

PATIENTS AND METHODS

Diagnostic, stage and surgical codes of patients with T1‐2N0M0 renal cell carcinoma treated with either PN or RN were assessed. Proportions, trends and multivariable logistic regression models tested the predictors of the use of PN.

RESULTS

Of 19 733 assessable patients, 2614 (13.2%) and 17 119 (86.8%), respectively, had PN or RN. The use of PN decreased with increasing tumour size, was more frequent in younger patients and increased with more contemporary years of surgery (all P < 0.001). Intriguingly, there was important geographical variability (P < 0.001), e.g. in the San Francisco‐Oakland Metropolitan Area the absolute PN rate was 16.4%, vs 7.6% in New Mexico (P < 0.001). In multivariable analyses, tumour size, age, year of surgery, gender and SEER registries were independent predictors of PN use.

CONCLUSION

Although as expected the rate of PN use increased over time, unexplained variability remained. For example, gender and SEER registries affected the likelihood of PN. These variables warrant further analyses to reduce unnecessary variability and to maximize PN use and its benefit.     

Outcomes of radical prostatectomy for patients with clinical stage T1a and T1b disease

OBJECTIVE

To compare the outcomes between patients with stage T1a/b with those of patients with T1c cancer of the prostate treated with radical retropubic prostatectomy (RRP), as the appropriate management of clinical stage T1a/b prostate cancer is subject to debate; although many patients are managed expectantly, some have adverse pathological features suggesting that more active treatment might be beneficial.

PATIENTS AND METHODS

From 1983 to 2003, 3478 men had RRP by one surgeon. From this group, we retrospectively identified 29 men with clinical stage T1a and 83 with clinical stage T1b disease. Using statistical analysis we compared the treatment outcomes of these patients with those of 1774 men with clinical stage T1c disease.

RESULTS

Men with T1a/b disease had a significantly lower preoperative prostate‐specific antigen (PSA) level, a greater proportion with organ‐confined disease, and a lower mean/median prostatectomy Gleason score than those with T1c disease. Also, men with T1a/b disease were less likely to be potent before surgery, although the frequency of recovery of potency was similar among all groups. On multivariate analysis with age, year of surgery, PSA level and Gleason score, there was no statistical difference in the rates of biochemical recurrence and the 10‐year overall survival rates. However, patients with T1b disease had a significantly lower cancer‐specific survival.

CONCLUSIONS

T1a and T1b prostate cancer can be associated with aggressive pathological features and have a similar rate of progression as clinical stage T1c disease. That notwithstanding, most patients in the study were cured with RRP and had favourable long‐term functional outcomes.     

Outcome of nephron‐sparing surgery for T1b renal cell carcinoma

OBJECTIVE

To present our experience with nephron‐sparing surgery (NSS) for T1b renal cell carcinoma (RCC) in a high‐volume tertiary referral centre. NSS for RCC of <4 cm (T1a) is increasingly accepted, although its role for RCC of 4–7 cm (T1b) remains controversial.

PATIENTS AND METHODS

The records of 67 consecutive patients who had NSS for RCC of 4–7 cm at our institution were reviewed retrospectively. Data were collected on surgical indications, tumour characteristics, complications, changes in serum creatinine level, time to recurrence and time to death. Clinical progression‐free survival (CPFS), overall survival (OS), cancer‐specific survival (CSS) rates were estimated statistically.

RESULTS

The mean patient age was 62 years. Surgical indications were absolute in 26 (39%) patients, relative in 11 (16%) and elective in 30 (45%). Two patients (3%) required postoperative embolization, and none developed a urinary fistula. Four patients (6%) had positive resection margins; none of these developed tumour recurrence. After a median (range) follow‐up of 40.1 (1–98.3) months, 10 patients (15%) had died, of whom only one death was related to NSS (postoperative hypovolaemic shock). The tumour recurred in seven patients (10%) all of whom were alive at the last follow‐up. Three patients (4%) developed a local recurrence and four (6%) developed locoregional or distant disease. The projected 5‐year CPFS, CSS and OS rates were 84%, 99% and 72%, respectively. Seven (10%) patients developed de novo renal insufficiency. Elective and relative indications were not associated with a significant change in serum creatinine level (P = 0.22 and 0.10, respectively); in the absolute category this difference was statistically significant (P = 0.005). The main limitation is that the study was uncontrolled and retrospective, with a medium‐term follow‐up.

CONCLUSIONS

This study showed the excellent surgical feasibility and CSS for NSS in T1b RCC. Local cancer control was achieved in the large majority of patients, with preservation of renal function in those with elective indications. Absolute indications significantly correlated with loss of renal function.