Residual renal function after partial or radical nephrectomy for renal cell carcinoma

Renal cell carcinoma (RCC) is often detected incidentally and early. Currently, open partial nephrectomy and laparoscopic total nephrectomy form competing technologies. The former is invasive, but nephron-sparing; the other is considered less invasive but with more loss of renal mass. Traditionally, emphasis has been placed on oncologic outcomes. However, a patient with an excellent oncologic outcome may suffer from morbidity and mortality related to renal failure. Animal models with hypertension and diabetic renal disease indicate accelerated progression of pre-existing disease after nephrectomy. Patients with RCC are older and they have a high prevalence of diabetes and hypertension. The progression of renal failure may also be accelerated after a nephrectomy. Our analysis of the available literature indicates that renal outcomes in RCC patients after surgery are relatively poorly defined. A strategy to systematically evaluate the renal function of patients with RCC, with joint discussion between the nephrologist and the oncologic team, is strongly advocated.     

Prognostic nomogram for renal insufficiency after radical or partial nephrectomy

PURPOSE: We analyzed prognostic factors to predict renal insufficiency after partial or radical nephrectomy. We developed and performed internal validations of a postoperative nomogram for this purpose. We used a prospectively updated renal tumor database of more than 1,500 patients. MATERIALS AND METHODS: From July 1989 to October 2003, 161 partial nephrectomies and 857 radical nephrectomies performed at Memorial Sloan-Kettering Cancer Center for renal cortical tumors were analyzed. Computerized tomography images were reviewed by a single radiologist. Kidney volume was calculated using the ellipsoid formula, V = L1 x L2 x L3 x pi/6, where V represents volume and L represents length. Renal insufficiency was defined by 2 serum creatinine values greater than 2.0 mg/dl at least 1 month postoperatively. Tumor histology was not an exclusion criterion and yet we excluded cases of bilateral synchronous disease. Prognostic variables were preoperative serum creatinine, American Society of Anesthesiologists score, percent change in kidney volume after surgery, and patient age and sex. RESULTS: Renal insufficiency was noted in 105 of the 857 patients with radical nephrectomy (12.3%) and in 6 of the 161 with partial nephrectomy (3.7%) studied. Patients had a median followup of 21.2 months (maximum 157.9). The 7-year probability of freedom from renal insufficiency in the cohort was 79.1% (95% CI 74.6 to 83.6). The nomogram was designed based on a Cox proportional hazards regression model. Following internal statistical validation nomogram predictions appeared accurate and discriminating with a concordance index of 0.835. CONCLUSIONS: A nomogram was developed that can predict the 7-year probability of renal insufficiency in patients undergoing radical or partial nephrectomy.     

Comparison of renal function detriments after local tumor ablation or partial nephrectomy for renal cell carcinoma

Purpose

Local tumor ablation (LTA) and partial nephrectomy (PN) represent treatment alternatives for patients diagnosed with small renal mass and both may result in renal function detriments. The aim of the study was to compare renal function detriments after LTA or PN.

Methods

A Surveillance epidemiology and End Results-Medicare-linked retrospective cohort of 2850 T1 kidney cancer patients who underwent LTA or PN was abstracted. Short-term outcomes consisted of 30-day acute kidney injury (AKI) and 30-day dialysis rates. Long-term outcomes consisted of episodes of AKI, mild and moderate–severe chronic kidney disease (CKD), end-stage renal disease, hemodialysis and anemia in CKD. Analyses consisted of propensity score matching, logistic and Cox regression.

Results

After propensity score matching, 1122 patients remained. The 30-day incidence of AKI was 4.6 % after LTA and 9.4 % after PN. In multivariable analyses (MVAs), LTA was associated with a lower AKI rate (OR 0.42; p = 0.001). The 30-day incidence of any dialysis was <2 % after either LTA or PN. In MVA, LTA was not associated with a lower rate of any dialysis (OR 0.43; p = 0.2). At long-term assessment, both the unadjusted and adjusted rates of all six examined end points were not different between LTA and PN (all p > 0.5).

Conclusions

LTA offers short-term protective effect from AKI. The short-term rates of any dialysis treatment are similar after either LTA or PN. At long-term assessment, LTA and PN renal function detriment rates are not different. Concern for long-term functional outcomes should not be a barrier for PN.

     

Renal function and adaptive changes in patients after radical or partial nephrectomy

Introduction

Renal function after renal surgery depends on the volume of renal parenchyma loss and improves in the postoperative period. However, the knowledge on kidney function after radical (RN) and partial (PN) nephrectomy is still insufficient. The aim of this study is to analyze the global renal function and compensatory hyperfunction of the non-operated kidney in patients with renal cancer after RN or PN.

Methods

Fifty-one patients of mean age 62.2?years with renal cancer were included. Thirty-three RN and eighteen PN were performed. We measured creatinine serum concentrations, and we estimated glomerular filtration rate (eGFR) preoperatively and postoperatively at two time intervals: 3 and 12?months after surgery. Additionally, we assessed effective renal plasma flow (ERPF) in dynamic scintigraphy preoperatively and 12?months after surgery.

Result

At the baseline, all mean measured values were comparable in RN and PN groups (P?>?0.05). Three?months after surgery, creatinine level increased in both groups, more remarkably in RN group (128?mmol/l vs. 95?mmol/l; P?2 vs. 70?ml/min/1.73?m²; P?P?>?0.05). The mean ERPF of the operated kidney in PN group decreased by 24.7% (149?ml/min).

Conclusion

The deterioration of renal function after partial nephrectomy is nearly insignificant clinically. In 1-year postoperative observation, the renal function does not improve. This causes potential compensatory mechanisms to be insufficient.     

Preservation of renal function following partial or radical nephrectomy using 24-hour creatinine clearance

OBJECTIVE: To compare the effect on renal function of partial and radical nephrectomy using creatinine clearance measurements from 24-hr urine collection. METHODS: All patients with a solid enhancing renal mass suspicious for renal cell carcinoma, a normal contralateral kidney, and not dialysis dependent were enrolled in this prospective cohort study. Patients were treated with partial or radical nephrectomy by one urologist. Creatinine clearance (CrCl) measurements were prospectively obtained by 24-hr urine collection preoperatively, and at 3, 6, and 12 mo postoperatively. Mean change in creatinine clearance from baseline was compared at 3, 6, and 12 mo. Serum creatinine and Cockcroft-Gault calculations were also performed for comparison. Mixed model analysis incorporating patient and tumor characteristics and the procedure type was performed in SAS Version 9.1. RESULTS: Sixty-three consecutive patients were enrolled in this study. The partial nephrectomy (n=26) and radical nephrectomy (n=37) groups were similar with respect to age, sex, presence of hypertension, vascular disease, diabetes mellitus, and angiotensin converting enzyme inhibitor or receptor blocker use. The postoperative change in creatinine clearance was significantly less (p-value < 0.0001) in the partial nephrectomy group (-0.09mL/s, -6.1%) compared to the radical nephrectomy group (-0.56mL/s, -31.6%). Linear regression analysis showed intervention type (partial vs. radical nephrectomy) was the most significant predictor of change in creatinine clearance (p-value < 0.0001). CONCLUSIONS: There is significantly less deterioration in the overall renal function of patients who are treated with partial nephrectomy compared to radical nephrectomy. This highlights the importance of performing nephron-sparing surgery on appropriate patients.     

Surveillance following radical or partial nephrectomy for renal cell carcinoma

Renal cell carcinoma (RCC) is the most lethal of the common urologic malignancies, with approximately 40% of patients eventually dying of cancer progression. Approximately one third of patients present with metastatic disease and up to 50% treated for localized disease have a recurrence. Although the prognosis generally is poor in these patients, some may respond to immunotherapy and a subset of patients who develop solitary metastases can achieve long-term survival. Therefore, the timely identification of recurrences following surgical extirpation is imperative in the treatment of patients.     

Predicting short- and long-term renal function following partial and radical nephrectomy

ObjectivesTo externally validate the previously published Mayo clinic model for the prediction of early (<30 days) postoperative renal failure, which relies solely on preoperative estimated glomerular filtration rate (eGFR) and develop a novel model for the prediction of long-term (>30 days) renal function after partial nephrectomy (PN) and radical nephrectomy (RN), including patient factors and nephrometry scores.Patients and methodsRetrospective, single-center cohort study on patients who underwent PN or RN for a unilateral renal tumor between 2003 and 2019 with a preoperative eGFR of at least 15 ml/min/1.73m². Early postoperative renal failure was defined as eGFR <15 ml/min/1.73 m² or receipt of dialysis within 30 days. We determined the area under the receiver operating characteristics curve (AUC) to assess the Mayo clinic model's discriminative power. We used hierarchical linear mixed models with backward selection of candidate variables to develop a prediction model for long-term eGFR following PN and RN, separately. Their predictive ability was quantified using the marginal and conditional R²_GLMM and an internal validation.ResultsWe included 421 patients (7,548 eGFR observations) who underwent PN and 271 patients (6,530 eGFR observations) who underwent RN. The Mayo clinic model for prediction of early postoperative renal failure following PN and RN showed an AUC of 0.816 (95% CI 0.718–0.920) and 0.825 (95% CI 0.688–0.962), respectively.In multivariable models, long-term eGFR following PN was associated with age, diabetes, the presence of a solitary kidney, tumor diameter and preoperative eGFR, while long-term eGFR following RN was associated with age, body mass index, RENAL nephrometry score and preoperative eGFR. Marginal and conditional R²_GLMM were 0.591 and 0.855 for the PN model, and 0.363 and 0.849 for the RN model, respectively.ConclusionsThe Mayo clinic model for short-term renal failure prediction showed good accuracy on external validation. Our long-term eGFR prediction models depend mostly on host factors as opposed to tumor complexity and can aid in decision-making when considering PN vs. RN.     

Natural history of chronic renal insufficiency after partial and radical nephrectomy

Objectives. To compare the incidence of newly developed chronic renal insufficiency after partial nephrectomy (PN) and radical nephrectomy (RN). Elective PN for renal tumors is intended to preserve renal function; however, studies of transplant donors suggest normal renal function is also maintained after unilateral nephrectomy.Methods. We retrospectively compared all patients undergoing PN or RN for renal tumors 4 cm or less in the presence of a normal contralateral kidney from 1989 to 2000. Creatinine failure was defined as a serum creatinine value greater than 2.0 mg/dL. Risk factors for renal insufficiency, including diabetes, hypertension, American Society of Anesthesiologists score, age, preoperative creatinine, and history of smoking tobacco, were compared between the two groups. We compared the two groups using the chi-square and Mann-Whitney U tests and the creatinine failure rates using the Kaplan-Meier method.Results. One hundred seventy-three patients met the criteria for analysis after RN and 117 did so after PN (median follow-up 25 months). The 5-year freedom from recurrence rate was 96.4% and 98.6% for PN and RN, respectively (P >0.05). The mean preoperative serum creatinine was 1.0 mg/dL (range 0.4 to 1.4) and 0.98 (range 0.6 to 1.5) for RN and PN, respectively (P = 0.4, not significant). The incidence of risk factors for renal insufficiency did not differ between the two groups. The mean postoperative serum creatinine in the RN and PN groups was 1.5 mg/dL (range 0.8 to 3.8) and 1.0 mg/dL (range 0.5 to 1.9), respectively (P <0.001). The chance of creatinine failure over time was significantly greater in the RN group (P = 0.008).Conclusions. When controlled for preoperative risk factors for renal insufficiency, patients undergoing RN are at a greater risk of chronic renal insufficiency than a similar cohort of patients undergoing PN.     

Surveillance after radical or partial nephrectomy for localized renal cell carcinoma and management of recurrent disease

Surveillance after surgery for RCC is important because approximately 50% of these patients will develop a disease recurrence, two thirds of who will recur within the first year. Although the prognosis is generally poor in these patients, some may respond favorably to immunotherapy. The small subset of patients who develop solitary metastases has the greatest chance to achieve long-term survival. Aggressive surgical resection is an integral part of this success. Proposed surveillance protocols using a stage-based approach or an integrated approach combining stage with other important prognostic factors attempt to provide a rational approach to identifying treatable recurrences while minimizing unnecessary examinations and patient anxiety. However, strict adherence to follow-up guidelines may not be appropriate for all patients. Factors including patient comorbidities and patient willingness to pursue aggressive management in the event of recurrence may alter the follow-up for each individual.     

肾癌根治术后连续观察肾功能变化的临床研究

目的 评估肾癌根治术后肾功能的影响因素以及肾功能的变化趋势.方法 2007年1月至2011年12月苏州大学附属第一医院行肾癌根治术连续入组356例患者,因失访、重大数据缺失等原因,最终参加研究分析的样本185例.男性121例,女性64例,年龄30 ～ 88岁,平均(58±12)岁.合并糖尿病34例,高血压病82例;开放手术132例,腹腔镜手术53例.连续监测患者术后3、6、9、12、24、36、48、60、72个月血清肌酐,通过肾脏病饮食调整方程(MDRD方程)计算出估计肾小球滤过率(eGFR),以线性混合模型分析术后eGFR的连续变化,以多因素回归分析影响术后肾功能变化的预后因素.结果 总体患者术后肾功能在持续恢复状态,直线斜率(β)为0.099(95％ CI:0.07～0.13,P＜0.01),即每月恢复0.099ml·min-1·(1.73 m2)-1.不同预后因素患者组与该因素参照组直线斜率(β)存在差异,多因素回归分析后,以下三组间差异具有统计学意义,结果分别为:糖尿病和非糖尿病患者直线斜率(β)分别为-0.02及0.12(P＜0.01),高血压和非高血压人群直线斜率(β)分别为0.08及0.11(P ＜0.05),≤50岁、＞50 ～ 65岁、＞65岁人群直线斜率(β)分别为0.15、0.09及0.05(P ＜0.05).术后新发慢性肾病13例,其中慢性肾病Ⅲ期9例,慢性肾病Ⅳ期4例.结论 肾癌根治术后肾功能随访期间一直处于恢复状态.肾功能预后良好因素包括低龄、无高血压及无糖尿病.     

Assessment of volume preservation performed before or after partial nephrectomy accurately predicts postoperative renal function: Results from a prospective multicenter study

Purpose

Partial nephrectomy (PN) is standard for small renal masses, improving renal function by preserving renal parenchyma compared with radical nephrectomy. Recent work demonstrated that postoperative surgeon assessment of volume preservation (SAVP) and 3D imaging measurements agree and correlate with postoperative function. We hypothesize preoperative assessment of volume preservation (PAVP) with PN based on preoperative imaging will reliably indicate postoperative renal function.

Surgical factors affecting return of renal function after partial nephrectomy

Introduction  

Nephron-sparing surgery is becoming the standard treatment for small renal tumors. In this study, we investigate the relationship between operative factors and recovery of renal function after partial nephrectomy.     

后腹腔镜肾部分切除术在治疗肾肿瘤的临床应用

目的探讨后腹腔镜保留肾单位的肾部分切除术治疗肾肿瘤的临床应用价值。方法 11例患者施行后腹腔镜保留肾单位的肾部分切除术的临床资料,其中男8例,女3例,年龄平均51.2岁,肿瘤直径3～4cm回顾性分析。结果所有手术均获成功,手术时间70～120min,血管阻断时间20～40min,术中失血100～300ml,术后无出血、尿漏等并发症。术后病理9例肾脏透明细胞癌(T1N0M0),2例肾血管平滑肌脂肪瘤,随访3～15个月无局部复发。结论后腹腔镜下保留肾单位的肾部分切除术治疗早期肾脏肿瘤,安全、有效,兼有创伤小,康复快等优点,近期疗效满意,远期疗效有待进一步观察。