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.

     

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.

     

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 in two patients with known T3a tumours involving the renal vein

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although nephron‐sparing surgery (NSS) has became accepted therapy for T1 tumours, radical nephrectony is considered the best therapy for T3a tumours involving the renal vein. NSS can be considered in T3a or greater tumours if imperative indications exist, such as bilateral disease or solitary kidney. However, there is little published data on the characteristics of these patients, the impact of surgery on their renal function, and long‐term oncologic outcomes. This study profiles single‐institution experience with nephron‐sparing surgery for known T3a tumours involving the renal vein, including patient characteristics, tumour characteristics, preoperative and follow‐up imaging, preoperative and follow‐up estimated glomerular filtration rate, length of temporary postoperative haemodialysis, and oncologic outcome. Additionally, we compare this to other published data on nephron‐sparing surgery for similar tumors.

OBJECTIVE

• ? To present two patients with T3a tumours involving the renal vein who underwent nephron‐sparing surgery (NSS) for imperative reasons.

PATIENTS AND METHODS

• ? Retrospective chart review of patients who underwent NSS for renal cell carcinoma (RCC) with known renal vein tumour thrombus (RVTT).
• ? Both patients underwent open partial nephrectomy and renal vein thrombectomy of a solitary kidney.
• ? Primary outcomes of the study include radiographic evidence of recurrence, haemodialysis requirement and estimated glomerular filtration rate (eGFR) before and after surgery.

RESULTS

• ? Patient 1 is 24 months from NSS and has no evidence of recurrence based on CT scan. His final pathology revealed a 9‐cm, T3a, clear cell, Fuhrman grade II carcinoma. He spent 42 days on haemodialysis and is now off all dialysis. His preoperative and most recent eGFR are 48 and 23 mL/min/1.73 m² based on the Modification of Diet in Renal Disease (MDRD) equation and 69.4 and 29.8 mL/min by the Cockcroft–Gault equation.
• ? Patient 2 is 9 months from NSS and has no evidence of recurrence based on CT scan. Her final pathology revealed a 6‐cm, T3a, clear cell, Fuhrman grade II–III carcinoma. She spent 30 days on haemodialysis and is now off all dialysis. Her preoperative and most recent eGFR are 58 and 30 mL/min/1.73 m² based on the MDRD equation and 62.2 and 32.8 mL/min by the Cockcroft–Gault equation.

CONCLUSION

• ? Based on our review, preservation of renal function and favourable oncological outcome can be accomplished with NSS in patients with known stage T3a RCC with RVTT and should be considered in carefully selected patients.

     

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.

     

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.

     

Evolving practice patterns for the management of small renal masses in the USA

Study Type – Therapy (trend analysis) Level of Evidence 2b What's known on the subject? and What does the study add? Treatment options for small renal masses include radical nephrectomy (RN), partial nephrectomy (PN), ablation, and surveillance. PN provides equivalent oncological as RN for small tumours, but long‐term outcomes for ablation and surveillance are poorly defined. Due to changing techniques and technology, treatment patterns for small renal masses are rapidly developing. Prior studies had analysed utilisation trends for PN and RN to 2006, revealing a relative rise in the rate of PN. However, overall treatment trends including surveillance and ablation had not been studied using a population‐based cohort. It has become increasingly clear that RN is associated with greater renal and cardiovascular deterioration than nephron‐sparing treatments. Thus, it is important to understand current population‐based practice patterns for the treatment of small renal masses to assess whether practitioners are adhering to ever‐changing principles in this field. The present study provides up‐to‐date treatment trends in the USA using a large population‐based cohort.

OBJECTIVE

• ? To describe the changing practice patterns in the management of small renal masses, including the use of surveillance and ablative techniques.

PATIENTS AND METHODS

• ? All patients in the Surveillance, Epidemiology and End Results (SEER) registry treated for renal masses of ≤7 cm in diameter, from 1998 to 2008, were included for analysis.
• ? Annual trends in the use of surveillance, ablation, partial nephrectomy (PN), and radical nephrectomy (RN) were calculated.
• ? Multinomial logistic regression was used to determine the association of demographic and clinical characteristics with treatment method.

RESULTS

• ? In all, 48 148 patients from 17 registry sites with a mean age of 63.4 years were included for analysis.
• ? Between 1998 and 2008, for masses of <2 cm and 2.1–4 cm, there was a dramatic increase in the proportion of patients undergoing PN (31% vs 50%, 16% vs 33%, respectively) and ablation (1% vs 11%, 2% vs 9%, respectively).
• ? In multivariable analysis, later year of diagnosis, male gender, being married, clinically localised disease, and smaller tumours were associated with increased use of PN vs RN. Later year of diagnosis, male gender, being unmarried, smaller tumour, and the presence of bilateral masses were associated with increased use of ablation and surveillance vs RN.

CONCLUSIONS

• ? PN is now used in half of all patients with the smallest renal masses, and its use continues to increase over time.
• ? Ablation and surveillance are less common overall, but there is increased usage over time in select populations.

     

Upper urinary tract transitional cell carcinoma: location is not correlated with prognosis

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Tumour location has been shown to be of prognostic importance in UUT‐TCC, with tumours of renal pelvis having a better prognosis than ureteral tumours. Patients from Balkan Endemic Nephropathy (BEN) areas had a higher frequency of pelvis tumours. Also, we found that belonging to a BEN area is an independent predictor of disease recurrence.

OBJECTIVE

• ? To identify the impact of tumour location on the disease recurrence and survival of patients who were treated surgically for upper urinary tract transitional cell carcinoma (UUT‐TCC).

PATIENTS AND METHODS

• ? A single‐centre series of 189 consecutive patients who were treated surgically for UUT‐TCC between January 1999 and December 2009 was evaluated.
• ? Patients who had previously undergone radical cystectomy, preoperative chemotherapy or contralateral UUT‐TCC were excluded.
• ? In all, 133 patients were available for evaluation. Tumour location was categorized as renal pelvis or ureter based on the location of the dominant tumour.
• ? Recurrence‐free probabilities and cancer‐specific survival were estimated using the Kaplan–Meier method and Cox regression analyses.

RESULTS

• ? The 5‐year recurrence‐free and cancer‐specific survival estimates for the cohort in the present study were 66% and 62%, respectively.
• ? The 5‐year bladder‐only recurrence‐free probability was 76%. Using multivariate analysis, only pT classification (hazard ratio, HR, 2.46; P= 0.04) and demographic characteristics (HR, 2.86 for areas of Balkan endemic nephropathy, vs non‐Balkan endemic nephropathy areas; 95% confidence interval, 1.37–5.98; P= 0.005) were associated with disease recurrence
• ? Tumour location was not associated with disease recurrence in any of the analyses.
• ? There was no difference in cancer‐specific survival between renal pelvis and ureteral tumours (P= 0.476).
• ? Using multivariate analysis, pT classification (HR, 8.04; P= 0.001) and lymph node status (HR, 4.73; P= 0.01) were the only independent predictors associated with a worse cancer‐specific survival.

CONCLUSION

• ? Tumour location is unable to predict outcomes in a single‐centre series of consecutive patients who were treated with radical nephroureterectomy for UUT‐TCC.

     

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.

     

Cryoablation vs radiofrequency ablation for the treatment of renal cell carcinoma: a meta-analysis of case series studies

Study Type – Therapy (systematic review) Level of Evidence 2b What's known on the subject? and What does the study add? The oncological success of partial nephrectomy in the treatment of small renal masses is well established. However, partial nephrectomy has largely supplanted the radical approach. In the last decade, laparoscopy has been adopted as the new surgical approach for the treatment of renal cell carcinoma. Laparoscopy offers the advantage of lower analgesic use, shorter hospital stay, and quicker recovery time. More recently, ablative technologies have been investigated as an alternative to laparoscopic partial nephrectomy. These techniques can often be performed percutaneously in the radiology suite, or laparoscopically without the need for hilar clamping. However, only the cryoablation and radiofrequency ablation modalities have had widespread use with several series reporting short to intermediate results. This review shows that both cryoablation and radiofrequency ablation are promising therapies in patients with small renal tumours (<4 cm), who are considered poor candidates for more involved surgery.

OBJECTIVE

• ? To determine the current status of the literature regarding the clinical efficacy and complication rates of cryoablation vs radiofrequency ablation in the treatment of small renal tumours.

METHODS

• ? A review of the literature was conducted. There was no language restriction. Studies were obtained from the following sources: MEDLINE, EMBASE and LILACS.
• ? Inclusion criteria were (i) case series design with more than one case reported, (ii) use of cryoablation or radiofrequency ablation, (iii) patients with renal cell carcinoma and, (iv) outcome reported as clinical efficacy.
• ? When available, we also quantified the complication rates from each included study.
• ? Proportional meta‐analysis was performed on both outcomes with a random‐effects model. The 95% confidential intervals were also calculated.

RESULTS

• ? Thirty‐one case series (20 cryoablation, 11 radiofrequency ablation) met all inclusion criteria.
• ? The pooled proportion of clinical efficacy was 89% in cryoablation therapy from a total of 457 cases. There was a statistically significant heterogeneity between these studies showing the inconsistency of clinical and methodological aspects.
• ? The pooled proportion of clinical efficacy was 90% in radiofrequency ablation therapy from a total of 426 cases. There was no statistically significant heterogeneity between these studies.
• ? There was no statistically significant difference regarding complications rate between cryoablation and radiofrequency ablation.

CONCLUSIONS

• ? This review shows that both ablation therapies have similar efficacy and complication rates.
• ? There is urgency for performing clinical trials with long‐term data to establish which intervention is most suitable for the treatment of small renal masses.

     

Laparoscopic partial nephrectomy for multiple tumours: feasibility and analysis of peri-operative outcomes

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Laparoscopic nephron‐sparing procedures have been increasingly utilized. However, in the presence of multiple tumours the procedure choice is usually shifted to radical nephrectomy. In view of favourable perioperative outcomes, the benefits of minimally‐invasive, nephron‐sparing surgery in experienced hands could be safely extended to patients presenting with multiple ipsilateral renal masses.

OBJECTIVE

• ? To describe our experience with laparoscopic partial nephrectomy (LPN) for multiple kidney tumours and compare the outcomes with LPN performed for single masses.

PATIENTS AND METHODS

• ? Retrospective analysis of medical records of patients undergoing LPN at our institution between 2005 and 2009 was performed.
• ? The cohort was divided in two groups based on tumour focality: group 1, LPN for a single tumour (n= 99) and group 2, LPN for multiple ipsilateral tumours (n= 12).
• ? The groups were compared with regards to demographic and peri‐operative variables.

RESULTS

• ? Demographic variables were not different between the groups. Median dominant tumour size was 3.1 cm (interquartile range [IQR] 2.4–4.0) and 4.0 cm (2.3–5.9) in groups 1 and 2, respectively.
• ? Median secondary tumour size in group 2 was 1.0 cm (1.0–1.8).
• ? Operative times were longer in group 2 compared with group 1 (220 vs 160 min, P= 0.009).
• ? Warm ischaemia times (WIT) (23 vs 22 min) and estimated blood loss (EBL) (100 vs 85 mL) were similar.

CONCLUSIONS

• ? LPN is a viable option for the treatment of multiple ipsilateral renal tumours.
• ? Peri‐operative outcomes are similar to standard LPN with the exception of longer operative time.
• ? In experienced hands, the advantages of minimally invasive surgery may be extended to select patients with ipsilateral multifocal renal tumours.

     

Under-grading of <4 cm renal masses on renal biopsy

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? It is well documented that biopsy of small renal masses is inaccurate and tends to under‐estimate tumour grade compared with surgical specimens. To our knowledge there has not been a study showing grading discrepancy between biopsy and surgical excision in a large population‐based cohort.

OBJECTIVE

• ? To determine whether differences exist in tumour grade between patients who undergo partial nephrectomy (PN) and those who undergo ablation for renal tumours.

PATIENTS AND METHODS

• ? Data was obtained using the Surveillance, Epidemiology and End Results database. Patients with solitary renal tumours of <4 cm treated with ablation or PN and with renal cell carcinoma (RCC) histopathology were identified.
• ? Tissue diagnosis in the ablation specimens was obtained from biopsy reports, whereas tissue from PN specimens was determined from surgical pathology.
• ? Variables analysed included: year of diagnosis, age, sex, race/ethnicity, marital status, population density, education, poverty level, and tumour size.
• ? Stacked bar graphs were created to compare the distributions of grade and histology between the groups. Multinomial logistic regression was used to determine factors independently associated with grade.

RESULTS

• ? In all, 7704 (87.4%) patients underwent PN and 1114 (12.6%) underwent either radiofrequency ablation or cryoablation.
• ? The PN patients were younger at diagnosis (59 vs 68 years, P < 0.001), more likely to be married (70% vs 64%, P < 0.001), and had smaller tumours (2.4 vs 2.6 cm, P < 0.001).
• ? There were no differences in the distribution of histology between the PN and ablation groups.
• ? Tumour grade was significantly lower in tumours treated with ablation.
• ? Compared with grade 1 disease, those undergoing ablation were 30% less likely to have grade 2 (P < 0.001), 30% less likely to have grade 3 (P < 0.001), and 92% less likely to have grade 4 disease (P < 0.01) than those having PN.

CONCLUSIONS

• ? There is a strong association between grade and treatment type in patients with small renal masses after controlling for baseline characteristics.
• ? As grade is determined by different methods, we think that this shows systematic under‐grading in biopsy of small renal masses.

     

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.

     

Suberoylanilide hydroxamic acid (SAHA) combined with bortezomib inhibits renal cancer growth by enhancing histone acetylation and protein ubiquitination synergistically

What's known on the subject? and What does the study add? The treatment modality for advanced renal cancer is limited and new treatment approaches are urgently needed. Beneficial effects of bortezomib combined with SAHA have recently been reported. However, there are no previous reports of this combination being tested against renal cancer and its further mechanisms of action should be clarified. This study examined the combined effects of these two clinically feasible drugs and showed that the combination inhibits renal cancer cell proliferation by enhancing both protein ubiquitination and histone acetylation synergistically.

OBJECTIVE

• ? To investigate the combined effect of two clinically feasible drugs, the proteasome inhibitor bortezomib and the histone deacetylase (HDAC) inhibitor suberoylanilide hydroxamic acid (SAHA), on human renal cancer cells in vitro and in vivo.

MATERIALS AND METHODS

• ? The effectiveness of the combination of bortezomib (10–20 nm ) and SAHA (1–5 µm ) on renal cancer cells (Caki‐1, ACHN, A‐498, 786‐O, 769‐P) was assessed by MTS assay, colony formation assay, cell cycle analysis, and apoptosis assay.
• ? In vivo efficacy was evaluated using murine subcutaneous (s.c.) tumour models.
• ? Protein ubiquitination, unfolded protein response, histone acetylation, and changes in the expression of HDAC were evaluated by western blotting.

RESULTS

• ? The combination of SAHA and bortezomib induced apoptosis and inhibited cancer cell proliferation synergistically (combination indices <1) and colony formation significantly (P < 0.05).
• ? In s.c. tumour models a 10‐day treatment with a combination of SAHA (50 mg/kg) and bortezomib (60 µg/kg) inhibited tumour growth significantly (P < 0.05).
• ? Mechanistically, SAHA combined with bortezomib enhanced protein ubiquitination synergistically and enhanced histone acetylation by inhibiting the expression of HDACs.

CONCLUSION

• ? SAHA combined with bortezomib inhibits the proliferation of renal cancer cells in vitro and in vivo, and the effectiveness of the combination is due to its synergistic enhancement of histone acetylation and protein ubiquitination.

     

Clinical efficacy and prognostic factors for overall survival in Japanese patients with metastatic renal cell cancer treated with sunitinib

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? A randomized prospective phase III clinical trial for systemic treatment‐naïve metastatic renal cell cancer (RCC) patients demonstrated the superiority of sunitinib over interferon with an acceptable safety profile. However, a commonly asked question is whether patients with RCC in clinical trials are representative of those with this disease being seen in ordinary clinical practice. To our knowledge, this is the first report of sunitinib for the Japanese patients with metastatic RCC in ordinary clinical practice. The estimated median PFS and OS in this study were 9.3 and 32.2 months, respectively. The application of the MSKCC model distinctly separated OS curves (P < 0.001), suggesting that MSKCC prognostic factors might be still valid to predict survival in metastatic RCC in the era of molecular targeted therapy.

OBJECTIVES

• ? To report the treatment efficacy and safety profile of sunitinib for patients with metastatic renal cell carcinoma (RCC) in ordinary clinical practice.
• ? In addition, to investigate the prognostic clinicopathological factors in these patients.

PATIENTS AND METHODS

• ? The present study consisted of native Japanese patients with metastatic RCC, comprising 29 pretreated and 34 systemic treatment‐naïve patients.
• ? Univariate and multivariate analyses were performed by the log‐rank test and the Cox proportional hazards model, respectively.

RESULTS

• ? Estimated median progression‐free survival and overall survival (OS) were 9.3 months (95% confidence interval, CI, 5.0–13.7) and 32.2 months (95% CI, 24.4–40.0), respectively.
• ? Among the patients pretreated before sunitinib, two patients were treated with initialized systemic therapy with sorafenib and the remaining 27 were initialized with interferon‐α.
• ? The OS from the initial systemic therapy of the patients in pretreated groups was 79.6 months (95% CI, 14.6–144.5).
• ? The application of the Memorial Sloan‐Kettering Cancer Center model distinctly separated the OS curves (P < 0.001).
• ? The most common grade 3 adverse events were fatigue (53%), thrombocytopaenia (48%), hand‐foot syndrome (16%), anaemia (20%), hypertension (10%) and leucopaenia (9%), although these events were manageable and reversible.

CONCLUSIONS

• ? Sunitinib has a favourable efficacy/safety profile for Japanese metastatic RCC patients in clinical practice.
• ? The estimated median OS was >2 years with acceptable tolerability.
• ? The median OS from the initial systemic therapy of the pretreated patients was >6 years.
• ? Memorial Sloan‐Kettering Cancer Center prognostic factors still appear to be valid for predicting survival in metastatic RCC in the era of molecular targeted therapy.

     

Treatment of loin pain suspected to be renal colic with papaverine hydrochloride: a prospective double-blind randomised study

Study Type – Therapy (RCT) Level of Evidence 1b What's known on the subject? and What does the study add? Results of our study showed that intravenous papaverine hydrochloride plus suppository sodium diclofenac were more effective than diclofenac sodium suppository alone in the treatment of acute renal colic. Therefore, intravenous papaverine hydrochloride may be a beneficial supplemental therapy to relieve renal colic pain, particularly in combination with NSAIDs.

OBJECTIVE

• ? To assess the efficacy of papaverine hydrochloride combined with a diclofenac sodium suppository to relieve renal colic compared with diclofenac suppository monotherapy, as the effect of phosphodiesterase inhibitors on ureteric muscles might reduce the pain of renal colic.

PATIENTS AND METHODS

• ? A prospective, double‐blind clinical study was performed.
• ? In all, 550 patients aged 17–55 years with acute renal colic were randomised to two groups. Patients in one group (group A) received a diclofenac suppository (100 mg) plus saline 0.9% (placebo) and the other group (group B) received a diclofenac suppository (100 mg) plus intravenous (i.v.) papaverine hydrochloride (1.5 mg/kg up to120 mg).
• ? Pain intensity was assessed using a visual analogue scale (VAS) at 0, 20 and 40 min after treatment. Further analgesia was provided at the patients' request (25 mg pethidine intramuscularly).

RESULTS

• ? Baseline characteristics (sex, age, past history of similar pains) were similar in the two groups.
• ? There were significant differences in VAS pain scores between 0 and 20 min and 0 and 40 min in both groups (P < 0.001).
• ? At the end of study, 71.1% of patients in group A and 90.9% of patients in group B reported pain relief and did not require pethidine, respectively.
• ? Significantly more patients in group A required further analgesia.

CONCLUSIONS

• ? According to our results, i.v. papaverine hydrochloride plus a diclofenac suppository were more effective than the diclofenac suppository alone for treating acute renal colic.
• ? Therefore, i.v. papaverine hydrochloride is a beneficial supplemental therapy to relieve renal colic pain, particularly combined with non‐steroidal anti‐inflammatory drugs.

     

Impact of pathological tumour characteristics in patients with sarcomatoid renal cell carcinoma

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Sarcomatoid renal cell carcinoma can occur in the setting of all histological subtypes of kidney cancer. These tumours are very aggressive and many patients present with disseminated disease. Long‐term survival is poor and the durable responses to systemic therapy are infrequent. Our large cohort analyses the influence of pathological tumour characteristics in determining prognosis for patients with sarcomatoid renal cell carcinoma undergoing surgical resection. This series helps define the prognostic influence of histological subtype, type of sarcomatoid morphology, the percentage necrosis and sarcomatoid features, and the presence of microvascular invasion.

OBJECTIVES

• ? To examine the influence of pathological tumour characteristics on survival to aid prognostication and clinical trial design.
• ? Patients with sarcomatoid renal cell carcinoma (sRCC) are known to have poor prognosis and response to systemic therapy.

PATIENTS AND METHODS

• ? A single‐centre database was reviewed to identify all patients with sRCC.
• ? Clinical variables and pathological information, including histology, necrosis, percentage of sarcomatoid features (PSF) and microvascular invasion (MVI), were recorded and correlated to outcome.

RESULTS

• ? Analyses of 104 patients with sRCC found that the median (range) size of tumours was 9.5 cm (2.5–30), 65% of patients had areas of clear cell histology, and 69.2% had metastatic disease at presentation.
• ? The PSF did not influence tumour size, stage, necrosis, MVI, nodes or metastasis.
• ? A total of 85 patients (81.7%) died during the follow‐up period with a median (95% confidence interval [CI]) survival of 5.9 months (4.7–8.9).
• ? In the overall cohort, Eastern Cooperative Group performance status (ECOGPS), tumour size and metastatic disease were independent predictors of poor survival. MVI, PSF and percentage necrosis were strongly associated with outcome but were not independent predictors of outcome.
• ? A multivariate risk model was established that incorporated six covariates (tumour size, MVI, ECOGPS, PSF, necrosis, and metastatic disease) to produce a predictive tool.

CONCLUSIONS

• ? Both patients with localized and metastatic sRCC have very poor survival outcomes.
• ? Pathological features MVI, PSF and necrosis are important predictors of survival and could be used in a prognostic model while grade and histology do not influence prognosis.
• ? A prognostic model, if validated, could aid in patient counselling and/or clinical trial design.