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.

     

Comparison of laparoscopic versus open radical nephrectomy for large renal tumors: a retrospective analysis of multi-center results

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? While laparoscopic radical nephrectomy (LRN) has been confirmed in various studies to be at least as efficacious as open radical nephrectomy (ORN) in terms of oncological control and more advantageous from the perspective of minimal invasiveness, very few studies have examined its feasibility and efficacy when applied to renal masses exceeding 7 cm in size, and even fewer involved results obtained from multicentre investigations. The present study retrospectively reviewed the outcome of LRN for masses exceeding 7 cm in size carried out in 26 institutions between 2000 and 2007 and concluded that LRN offers results comparable to ORN in terms of both tumour control and procedure‐associated morbidities. Furthermore, details from the study suggest that while the size of renal mass that can be treated using LRN may not be a necessarily limiting factor, the experience of the laparoscopic surgeon is a primary determinant in the overall outcome.

OBJECTIVE

• ? To assess the feasibility and oncologic efficacy of laparoscopic radical nephrectomy (LRN) compared with open radical nephrectomy (ORN) in patients with large renal cell carcinomas (RCCs) >7 cm in size.

PATIENTS AND METHODS

• ? We analysed the data from 255 patients who underwent radical nephrectomies at 26 institutions in Korea between January 2000 and December 2007 for RCCs > 7 cm in size.
• ? Eighty‐eight patients who underwent LRNs were compared with 167 patients who underwent ORNs. The patients with tumor thrombi in the renal vein or IVC, and lymph node or distant metastases were excluded.
• ? We compared the operative time, estimated blood loss, complication rates, and 2‐year overall and disease‐free survival rates between the LRN and ORN groups.

RESULTS

• ? The median duration of postoperative follow‐up was 19 months for the LRN group and 25.8 months for the ORN group.
• ? The operative time was significantly longer in the LRN group than in the ORN group (241.5 ± 74.8 min vs 202.7 ± 69.6 min, P < 0.001) and blood loss was significantly lower in the LRN group than in the ORN group (439.8 ± 326.8 mL vs 604.4 ± 531.4 mL, P = 0.006).
• ? No statistically significant difference was found in complication rates, the 2‐year overall (92.7% vs 94%, P = 0.586) and disease‐specific (90.1% vs 93.7%, P = 0.314) survival rates between the LRN and ORN groups.

CONCLUSIONS

• ? Despite the longer operative time, LRN was an effective and less invasive treatment option for clinical T2 renal tumors. It achieved a degree of cancer control similar to that obtained with ORN.

     

Transperitoneal versus retroperitoneal laparoscopic radical nephrectomy: A comparative study

Objectives:   To compare perioperative outcome of transperitoneal and retroperitoneal approaches during laparoscopic radical nephrectomy (LRN) and to identify selection criteria for each approach.
Methods:   Over a 7-year period, 100 consecutive patients (median age 62 years, range 20–80) underwent LRN for a renal tumor with clinical stage T1a–T3a. The first choice approach was retroperitoneal. The transperitoneal approach was chosen in selected cases based on tumor characteristics. Thirty-three patients underwent the transperitoneal approach, and 67 had the retroperitoneal approach. Perioperative parameters including operative time, blood loss and complications and pathology data were retrospectively analyzed.
Results:   Overall, 33 transperitoneal laparoscopic radical nephrectomies (TLRN) and 67 retroperitoneal laparoscopic radical nephrectomies (RLRN) were carried out. There was a statistically significant difference between the two groups in terms of size (5.3 vs 3.0 cm, P  < 0.0001) and clinical T stage (higher in the TLRN group, P  < 0.0001) of the tumors. Intraoperative complications included bradycardia, pneumothorax, renal vein injury, and renal artery injury in the TLRN group, and pneumothorax in the RLRN group. There were no differences in terms of operative time, blood loss and tumor grade between the two groups.
Conclusions:   Retroperitoneal and transperitoneal approaches yielded excellent surgical outcomes. The transperitoneal approach should be chosen based on tumor size and location to minimize vascular injury.     

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.

     

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.

     

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.

     

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.

     

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.

     

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.

     

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.

     

Comparison of transperitoneal and retroperitoneal laparoscopic nephrectomy for renal cell carcinoma: A single‐center experience of 100 cases

Objectives: To report our experience with the retroperitoneal and transperitoneal approaches of laparoscopic nephrectomy for renal cell carcinoma (RCC). Methods: Between July 2001 and December 2007, 100 patients with RCC underwent laparoscopic radical nephrectomy at our institution for clinically localized RCC. Fifty‐three patients received a retroperitoneal procedure and 47 received a transperitoneal procedure. The perioperative and oncological outcomes of these groups were reviewed retrospectively. Results: Mean follow up was 34 months. No statistically significant difference was found between the two approaches in terms of pathological stage, operative time, need for additional procedures such as adrenalectomy and/or lymph node sampling, estimated blood loss, need for blood transfusions, analgesic requirement, length of hospital stay, or the incidence of minor or major complications. The 5‐year disease‐free survival rate was 90% for both the retroperitoneal and transperitoneal procedures. The 5‐year overall survival rates were 98% and 96%, respectively. Therefore, no significant difference was observed in the long‐term oncological outcome between the two groups. Conclusions: Tumor control and surgical morbidity in laparoscopic radical nephrectomy seem not to be significantly influenced by the approach.     

Predictors of early mortality after radical nephrectomy with renal vein or inferior vena cava thrombectomy – a population‐based study

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Surgical volume has been well established as a predictor of outcomes for several complex surgical procedures, yet few studies have evaluated this relationship with regards to radical nephrectomy with either renal vein or inferior vena cava thrombectomy. In addition, most published literature consists of single‐institution series from centres of excellence. We performed a population‐level analysis and identified surgeon volume as a significant predictor of short‐term mortality for this procedure. Such findings have potential implications regarding future policy and regionalization of care.

OBJECTIVE

• ? To study the short‐term mortality associated with radical nephrectomy with renal vein or inferior vena cava thrombectomy and the variables associated with this adverse outcome.

METHODS

• ? Using the Ontario Cancer Registry, we identified 433 patients in the province of Ontario, Canada undergoing radical nephrectomy with venous thrombectomy between 1995 and 2004.
• ? We determined mortality rates at postoperative days 30 and 90.
• ? Other variables analysed include pathological tumour characteristics, surgeon graduation year, hospital/surgeon academic status, surgery year and hospital/surgeon volume.
• ? We used multivariable logistic regression to assess outcomes.

RESULTS

• ? Overall mortality was 2.8% (30‐day) and 5.8% (90‐day).
• ? Surgeons performing a single nephrectomy with venous thrombectomy performed 14% of the cases and had the highest 30‐day (6.7%) and 90‐day (10%) mortality. The mortality rate for surgeons performing more than one surgery was 2.1% (30‐day) and 5.1% (90‐day).
• ? In recent years, this procedure was performed more commonly by the highest volume surgeons – 67% of cases in 2004 vs 40% in 1995.
• ? Significant predictors of 30‐day mortality included procedure year and low surgeon volume.
• ? Significant predictors of 90‐day mortality included procedure year, low surgeon volume, left‐sided tumour and increasing hospital volume.

CONCLUSIONS

• ? For radical nephrectomy with venous thrombectomy, surgeon volume predicts short‐term mortality, emphasizing the importance of experience in patient outcome.
• ? Despite a shift towards high‐volume surgeons, 13.8% of cases continued to be performed by low‐volume providers.
• ? If these results are confirmed in other jurisdictions, radical nephrectomy with venous thrombectomy should be regionalized and performed by surgeons who manage these cases regularly.

     

Nicorandil‐induced penile ulcerations: a case series

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Partial nephrectomy is the standard treatment for the management of small renal masses, and laparoscopy has been widely used in this setting as it has all the principles of open procedures combined with the advantages of minimal invasiveness. Laparoscopic partial nephrectomy is feasible and has acceptable pathological results not only for small renal masses but also for large tumours, even if complication rate and ischemia time are still matters of debate.

OBJECTIVE

• ? To investigate the perioperative safety of laparoscopic partial nephrectomy (LPN) for large renal masses (>4 cm).

PATIENTS AND METHODS

• ? After Institutional Review Board approval, data from 100 consecutive patients who had undergone transperitoneal or retroperitoneal LPN at our institution from January 2005 to June 2009 were obtained from our prospectively maintained database.
• ? The patients were divided into two groups according to radiological tumour size: group A (67 patients) with tumours ≤4 cm and group B (33 patients) with tumours >4 cm.
• ? Demographic, perioperative and pathological data were evaluated.

RESULTS

• ? The two groups were comparable in terms of demographic data. Mean tumour size was 2.4 and 5 cm (P= 0.0001) for groups A and B, respectively. Group B tumours were more complex, as reflected by significantly more with a central location (P= 0.002), and by significantly more transperitoneal LPNs, pelvicalyceal repairs and longer warm ischaemia time (WIT; 19 vs 28 min).
• ? Complications were recorded in nine group A patients (13.4%) and nine group B patients (27.2%) (P= 0.09).
• ? There was no difference between preoperative and postoperative serum creatinine levels in either group, while a significant difference was found in postoperative estimated glomerular filtration rate between groups (P= 0.004).
• ? The incidence of carcinoma was comparable between the two groups.
• ? The incidence of positive surgical margins (PSMs) was 3.9% in group A, whereas no PSM was recorded in group B (P= 0.3).

CONCLUSIONS

• ? Laparoscopic partial nephrectomy for large tumours is feasible and has acceptable pathological results. However, the complication rate, in particular WIT, remains questionable.
• ? Further studies are required to better clarify the role of LPN in the management of tumours of this size.

     

Is robotic technology facilitating the minimally invasive approach to partial nephrectomy?

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Open partial nephrectomy has been defined as the standard of care for the treatment of small renal masses. Robotic platforms may offer the solution to bridge the gap between open and laparoscopic approaches, providing similar oncological and functional results via a shorter learning curve. This study reviews the current literature, and reports developments in robotic‐assisted partial nephrectomy (RPN). It highlights the important results from various studies which investigate the oncological and functional efficacy of RPN, and establishes its current status as at least equivalent to the laparoscopic approach. Trends are emerging that highlight the advantage of the robotic interface in facilitating this approach, and we postulate that this may become more apparent in future studies.

OBJECTIVE

• ? To establish its current status, this study reviews the literature, and reports developments in robotic‐assisted partial nephrectomy (RPN), highlighting results from various studies that investigate the oncological and functional efficacy of RPN. Partial nephrectomy has become the standard therapy for the management of small renal masses. In an effort to overcome the perioperative morbidity associated with an open approach, and the extended warm ischaemia times associated with a laparoscopic approach, robotic platforms have been introduced.

PATIENTS AND METHODS

• ? A search of Medline, EMBASE and Cochrane library databases was completed in July 2010 and used to identify pertinent original articles, editorials, comments and reviews, using the search term ‘partial nephrectomy’. Links to related references were surveyed, and all articles finally included were based on relevance and importance of content, as determined by the authors.

RESULTS

• ? The robotic platform may offer the solution to bridge the gap between open and laparoscopic approaches, achieving warm ischaemia times that consistently average 20 minutes, and providing similar oncological and functional results via a shorter learning curve. It offers cosmesis and convalescence equivalent to that from laparoscopic partial nephrectomy, but with potentially fewer postoperative complications.

CONCLUSION

• ? In terms of oncological and functional outcomes, the early experiences of RPN in selected series of patients appear at least equivalent to open and laparoscopic partial nephrectomy series. Randomized comparisons between the approaches are lacking, as are longer‐term follow‐up data for the robotic technique and formal cost analysis; these will be necessary before RPN can replace open partial nephrectomy as the new standard for the management of small renal masses. Trends continue to emerge that highlight the advantage of using the robotic platform to achieve a minimally invasive approach for partial nephrectomy, and with time and increasing expertise, this may become further apparent.

     

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.

     

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.

     

Impact of comorbidity on complications after nephrectomy: use of the Clavien Classification of Surgical Complications

Study Type – Retrospective (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Tumour characteristics, physical status and comorbidities are considered important for surgical outcome and prognosis. The present study objectively evaluates the association between comorbidity and postoperative complications after nephrectomy for RCC, by using the modified Clavien Classification of Surgical Complications to grade complications after nephrectomy.

OBJECTIVE

• ? To present a single‐centre experience of open nephrectomy for lesions suspected for renal cell carcinoma (RCC), evaluating the association between comorbidity and postoperative complications using a standardized classification system for postoperative complications.

PATIENTS AND METHODS

• ? Clinicopathological data of 198 patients undergoing open radical or partial nephrectomy for lesions suspected of RCC were retrospectively analysed.
• ? Comorbidity scored by the Charlson comorbidity index (CCI), body mass index, age, gender, surgical procedure and surgical history were examined as predictive factors for postoperative complications, which were scored using the modified Clavien Classification of Surgical Complications (CCSC).

RESULTS

• ? The overall complication rate was 34%: 7% grade I, 15% grade II, 5% grade III, 3% grade IV and 4% grade V. Preoperative comorbidities were present in 51% of all patients.
• ? There were significantly more major complications (CCSC >2) in patients with major comorbidities (CCI >2), at 16% vs 7% (P= 0.018).
• ? Patients with high‐stage RCC had significantly more severe complications than low‐stage RCC (P= 0.018).
• ? In multivariable analysis, comorbidity (odds ratio [OR] 7.55, P= 0.004) and tumour stage 3–4 (OR 6.23, P= 0.007) were independent predictive factors for major complications.

CONCLUSIONS

• ? Major complications occur significantly more often when major comorbidities are present.
• ? Comorbidity scores can be used in risk stratification for complications and should be considered during decision‐making and counselling of patients before nephrectomy.

     

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.

     

Combined p53 and MDM2 biomarker analysis shows a unique pattern of expression associated with poor prognosis in patients with renal cell carcinoma undergoing radical nephrectomy

What's known on the subject? and What does the study add? Unlike most other cancers mutations of the p53 gene (TP53), typically indicated by increased p53 expression, are rare in renal cell carcinomas (RCC) and there is no evidence that mutation of TP53 is associated with outcome or treatment response. However, whilst TP53 mutations are not linked with outcome, p53 expression is as we show here. Our study is the first to demonstrate simultaneously that patients with increased p53 expression (significantly associated with MDM2 expression), have reduced disease specific survival even though the expressed p53 is rarely mutated. We therefore identify increased expression of wild‐type p53 and MDM2 in RCC as targets for future therapeutic approaches.

OBJECTIVE

• ? To resolve much debated issues surrounding p53 function, expression and mutation in renal cell carcinoma (RCC), we performed the first study to simultaneously determine p53/MDM2 expression, TP53 mutational status (in p53‐positive patients) and outcome in RCC.

PATIENTS AND METHODS

• ? In total, 90 specimens obtained from patients with RCC, who were treated by radical nephrectomy, were analyzed by immunohistochemistry for p53 and MDM2 on a tissue microarray, and p53 was functionally and genetically analyzed in p53 positive samples.
• ? Outcome analysis was by the Kaplan–Meier method and univariate analysis was used to identify variables for subsequent multivariate analysis of correlations between clinical parameters and biomarker expression.

RESULTS

• ? Up‐regulation of p53 in RCC is strongly linked with MDM2 up‐regulation (P < 0.001).
• ? Increased coexpression of p53 and MDM2 identifies those patients with a significantly reduced disease‐specific survival by univariate (P= 0.036) and Cox multiple regression analysis (P= 0.027; relative risk, 3.20).
• ? Functional (i.e. functional analysis of separated alleles in yeast) and genetic analysis of tumours with increased p53 expression shows that most patients (86%) retain wild‐type p53.

CONCLUSIONS

• ? Coexpression of p53/MDM2 identifies a subset of patients with poor prognosis, despite all of them having organ‐confined disease.
• ? Up‐regulated p53 is typically wild‐type and thus provides a mechanistic explanation for the association between p53 and MDM2 expression: up‐regulated wild‐type p53 likely promotes the observed MDM2 coexpression.
• ? The results obtained in the present study suggest that the p53 pathway is altered in a tissue/disease‐specific manner and that therapeutic strategies targeting this pathway should be investigated to determine whether the tumour suppressive function of p53 can be rescued in RCC.