Tumour size, tumour complexity, and surgical approach are associated with nephrectomy type in small renal cortical tumours treated electively

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although the benefits of nephron‐sparing renal cortical tumour treatments are now widely accepted and have robust data supporting their oncological efficacy, safety, and positive effect on medium‐ and long‐term renal function, the decision to perform partial nephrectomy (PN) remains a complex interaction between several competing factors. Various patient factors, e.g. comorbid conditions, age, body habitus, patient preference, etc. may effect this decision. Then there are the preferences of the surgeon him‐ or herself, including faculty with different operative techniques and surgical approaches, which may lead to one treatment decision over another. Finally, the anatomy of the tumour itself, i.e. the complexity of the tumour within the kidney and anatomical relationships within the organ, is intuitively critical to a surgeon's assessment of resectability. There is very little published data indicating which of the multitude of clinical variables have the greatest impact on the decision to perform PN. Most previous investigations into the subject have focused on either imperative or relative indications for PN (i.e. solitary kidney, bilateral renal masses, and multifocal tumours) or have used maximal tumour diameter (i.e. tumour size) alone in their assessment of the clinical variables associated with PN use.

OBJECTIVE

• ? To identify preoperative variables associated with choice of partial nephrectomy (PN) vs radical nephrectomy (RN).

PATIENTS AND METHODS

• ? Between January 2004 and June 2008, 203 patients were treated for clinical T1a renal cortical tumours. Of these, 154 (75.8%) had all data available and form the analytic cohort.
• ? Patients were categorized into two groups, PN and RN, based on preoperative treatment plan.
• ? Patient‐, procedure‐, and tumour‐related variables, together with tumour complexity (based on the R.E.N.A.L Nephrometry Score [RENAL‐NS]) were evaluated for their association with planned PN vs RN.

RESULTS

• ? PN was planned in 120/154 patients (77.9%).
• ? Minimally invasive surgical approaches were planned in 66/154 cases overall (42.9%) and in 40/120 PN cases (33.3%).
• ? On univariate analysis, lower American Society of Anesthesiologists (ASA) score, planned open approach, smaller tumour size, left‐sided tumour, and lower RENAL‐NS were associated with planned PN.
• ? On multivariate analysis three factors remained independently associated with PN: tumour size (each 1 cm decrease in tumour size odds ratio [OR] 2.2, 95% confidence interval [CI] 1.2–4.0, P= 0.011), tumour complexity quantified by RENAL‐NS (each 1 point decrease OR 2.4, 95% CI 1.5–3.7, P < 0.001), and planned open surgical approach (OR 7.3, 95% CI 2.2–25, P= 0.001).

CONCLUSIONS

• ? The decision to perform elective PN is based primarily on tumour anatomical features but is also associated with surgical approach.
• ? The RENAL‐NS accurately predicts nephrectomy type in clinical T1a renal cortical tumours.

     

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

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

     

Comparison of rates and risk factors for development of anaemia and erythropoiesis-stimulating agent utilization after radical or partial nephrectomy

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The consequences and significance of iatrogenically‐induced CKD are poorly understood. Most data regarding risk of CKD and its complications are inferred from the medical literature. This is the first study to examine impact of surgical management of renal masses on development of anaemia. Patients who underwent radical nephrectomy had a significantly higher incidence of anaemia and ESA utilization than a contemporary well‐matched cohort that underwent partial nephrectomy. The results obtained add to the growing body of data supporting the use of partial nephrectomy in the management of clinically appropriate renal masses.

OBJECTIVE

• ? To examine the incidence of and risk factors for the development of anaemia and erythropoiesis‐stimulation agent (ESA) treatment in patients undergoing radical nephrectomy (RN) and partial nephrectomy (PN) because anaemia is a significant cause of morbidity in chronic kidney disease.

PATIENTS AND METHODS

• ? The study comprised a retrospective review of 905 patients (610 RN/295 PN; mean age, 57.5 years; mean follow‐up, 6.4 years) who underwent surgery for renal tumours at two institutions from July 1987 to June 2007.
• ? Demographics, disease characteristics and pre‐ and postoperative (i.e. renal function, metabolic parameters, anaemia and ESA treatment) were recorded.
• ? Data were analyzed within subgroups based on treatment (RN vs PN).
• ? Multivariate analysis was conducted to determine the risk factors for developing anaemia after surgery.

RESULTS

• ? Tumour size (cm) was significantly larger for RN (RN 7.0 vs PN 3.7; P < 0.001). No significant differences were noted with respect to demographics and preoperative anaemia (RN 16.4% vs PN 18.6%; P= 0.454) and ESA‐treatment (RN 0.7% vs PN 1.4%; P= 0.499).
• ? After surgery, significantly less de novo anaemia (PN 4.1% vs RN 17.5%; P < 0.001) and ESA utilization (PN 2.7% vs RN 13.4%; P < 0.001) occurred in the PN cohort.
• ? Multivariate analysis showed that age ≥60 years (odds ratio, OR, 1.62; P= 0.008), African American ethnicity (OR, 2.30; P < 0.001), smoking (OR, 1.60; P= 0.013), glomerular filtration rate (GFR) <60 mL/min/1.73 m² (OR, 4.09; P < 0.001), ≥1+ proteinuria (OR, 2.19; P < 0.03), metabolic acidosis (OR, 4.08; P= 0.007) and RN (OR, 2.58; P < 0.001) were significantly associated with de novo anaemia.

CONCLUSIONS

• ? Patients who underwent RN had a significantly higher prevalence of anaemia and ESA‐treatment compared to a well‐matched cohort that underwent PN.
• ? In addition to RN, age ≥60 years, African American ethnicity, history of smoking, GFR < 60 mL/min/1.73 m², proteinuria and metabolic acidosis were associated with developing anaemia.

     

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.

     

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.

     

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.

     

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.

     

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.

     

Trends in the use of of nephron-sparing surgery (NSS) at an Australian tertiary referral centre: an analysis of surgical decision-making using the R.E.N.A.L. nephrometry scoring system

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Nephron‐sparing surgery (NSS) is increasingly recognised as a preferred form of management for the incidentally detected small renal mass (SRM). Within the context of equivalent oncological outcomes, patients treated by NSS may have a survival advantage over those treated by radical nephrectomy (RN) through a reduced risk of chronic kidney disease and its associated cardiac morbidity. Despite this, according to Medicare data from the USA, a disproportionate number of patients with SRMs continue to be treated with RN instead of NSS. Similar data from Australia are not yet available. The present study explores the evolving management of SRMs at an Australian tertiary centre over a 5‐year period. It utilises the R.E.N.A.L. Nephrometry Score to assess how lesion complexity has influenced surgical decision‐making and charts the increasing use of NSS in the management of low‐complexity renal masses at our centre.

OBJECTIVE

• ? To examine recent trends in the use of nephron‐sparing surgery (NSS) at our centre. Specifically, we sought to examine the process of surgical decision‐making by applying the R.E.N.A.L. nephrometry scoring system to assess the complexity of lesions for which surgery was undertaken.

PATIENTS AND METHODS

• ? We performed a retrospective review of renal masses treated by surgery from January 2005 to December 2009, including 79 RN and 70 NSS.
• ? CT images were available for analysis in 50 patients within each group.
• ? Lesions were scored on the basis of their complexity using the R.E.N.A.L. nephrometry scoring system developed by Kutikov and Uzzo.

RESULTS

• ? There was no difference in age between patients undergoing RN and NSS (median age 61 vs 60 years).
• ? RN was performed for significantly larger lesions (mean [sd ] 68 [9] vs 29 [2] mm, P < 0.05) of predominantly moderate and high complexity (12% low, 56% moderate, 32% high).
• ? NSS was primarily used for low‐complexity lesions, but included four (8%) moderate‐complexity lesions in the final 2 years of the study.
• ? The use of NSS increased from 28.6% of cases in 2005 to 60.0% of cases in 2009, which mirrored the increase in the proportion of operations performed for low‐complexity lesions (22.2% low‐complexity in 2005 to 70.6% in 2009, P < 0.01 for trend).

CONCLUSIONS

• ? The increasing use of NSS at our institution mirrored the increasing treatment of low‐complexity renal lesions.
• ? This may reflect an increased detection and referral of such lesions, or a shift towards treatment of lesions that in the past would have been under surveillance.
• ? Practice at our centre reflects a shifting paradigm towards preferential use of NSS for the treatment of suitable renal masses.

     

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

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

     

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.

     

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.

     

Open radical prostatectomy in the elderly: a case for concern?

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Adverse outcomes after radical prostatectomy are more often recorded in the elderly. In the USA, elderly patients undergoing radical prostatectomy are treated at institutions where suboptimal outcomes are recorded.

OBJECTIVE

• ? To assess the rate of adverse outcomes after open radical prostatectomy (ORP) in the elderly and to examine the effect of annual hospital caseload (AHC) and academic institutional status on adverse outcomes in these of patients.

PATIENTS AND METHODS

• ? Within the Health Care Utilization Project Nationwide Inpatient Sample, we focused on ORPs performed between 1998 and 2007. Subsequently, we restricted to patients aged ≥75 years.
• ? In both datasets, we examined transfusion rates, intra‐operative and postoperative complication rates, and in‐hospital mortality rates.
• ? Stratification was performed according to AHC tertiles and academic status.
• ? Multivariable logistic regression analyses were fitted.

RESULTS

• ? Of 115 554 ORP patients, 2109 (1.8%) were aged ≥75 years.
• ? In multivariable analyses performed in the entire cohort, elderly age increased homologous blood transfusion rates (P < 0.001), intra‐operative (P= 0.001) and postoperative (P < 0.001) complication rates, and the mortality rate (P= 0.007).
• ? Most elderly were treated at low or intermediate AHC (68.5%) and non‐academic centres (56.2%).
• ? Within the elderly cohort, intra‐operative (2.9%) and postoperative (22.2%) complications tended to be highest at low AHC institutions compared to institutions of intermediate (2.7% and 17.4%) and high AHC (1.7% and 14.5%). Similarly, intra‐operative (2.7% vs 2.1%) and postoperative complications (19.1% vs 13.9%) tended to be higher at non‐academic than academic centres.
• ? In multivariable analyses performed in the elderly subgroup, low AHC predicted higher intra‐operative complications and higher homologous transfusions, whereas non‐academic status predicted higher postoperative complications.

CONCLUSIONS

• ? Adverse outcomes are more often recorded in the elderly.
• ? Most elderly are treated at institutions where suboptimal outcomes are recorded.

     

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.

     

'Zero ischaemia', sutureless laparoscopic partial nephrectomy for renal tumours with a low nephrometry score

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Ischaemic injury produced by hilar clamping during partial nephrectomy is the main determinant of renal function loss. The exact measurement of ipsilateral renal function loss can be underestimated by serum creatinine levels and estimated GFR. Few reports of unclamped laparoscopic partial nephrectomy (LPN) are available in the literature, although this technique shows promising results. The present study includes a series of patients with the longest follow‐up of LPN without hilar clamping and without parenchymal reconstruction. Excellent cancer control and optimum renal functional preservation suggest that this technique could be performed in selected patients, i.e. those with small and peripheral tumours (also classified as low nephrometry score tumours).

OBJECTIVE

• ? To describe the technique and report the results of ‘zero ischaemia’, sutureless laparoscopic partial nephrectomy (LPN) for renal tumours with a low nephrometry score.

PATIENTS AND METHODS

• ? Between August 2003 and January 2010, data from 101 consecutive patients who underwent ‘zero ischaemia’, sutureless LPN were collected in a prospectively maintained database.
• ? Inclusion criteria were tumour size ≤4 cm, predominant exophytic growth and intraparenchymal depth ≤1.5 cm, with a minimum distance of 5 mm from the urinary collecting system.
• ? Hilar vessels were not isolated, tumour dissection was performed with 10‐mm LigaSure^TM (Covidien, Boulder, CO, USA) and haemostasis was performed with coagulation and biological haemostatic agents without reconstructing the renal parenchyma.
• ? Clinical, perioperative and follow‐up data were collected prospectively, and modifications of functional outcome variables were analysed using the paired Wilcoxon test.

RESULTS

• ? The median (range) tumour size was 2.4 (1.5–4) cm, and the median (range) intraparenchymal depth was 0.7 (0.4–1.4) cm.
• ? Hilar clamping was not necessary in any patient, and suture was performed in four patients to ensure complete haemostasis. The median (range) operation duration was 60 (45–160) min, and median (range) intraoperative blood loss was 100 (20–240) mL.
• ? Postoperative complications included fever (n= 4), low urinary output (n= 3) and haematoma, which was treated conservatively (n= 2). The median (range) hospital stay was 3 (2–5) days. The pathologist reported 30 benign tumours and renal cell carcinoma in 71 cases (pT1a in 69 patients, and pT1b in two patients).
• ? At a median follow‐up of 57 months, one patient underwent radical nephrectomy for ipsilateral recurrence. The 1‐year median (range) decrease of split renal function at renal scintigraphy was 1 (0–5) %.

CONCLUSIONS

• ? Zero ischaemia LPN is a reasonable approach to treating small and peripheral tumours, and a sutureless procedure is feasible in most cases.
• ? This technique has a low complication rate and provides excellent functional outcome without impairing oncological results.

     

Delayed proximal ureteric stricture formation after complex partial nephrectomy

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? As the indications for nephron sparing surgery continue to evolve, so do the potential complications. This study examines a rare but likely underreported complication of nephron sparing surgery in order to better counsel and treat patients with complex renal tumours.

OBJECTIVE

• ? To report and review our incidence of delayed ureteric stricture (US) after complex nephron‐sparing surgery (NSS).

PATIENTS AND METHODS

• ? Using our institutional kidney cancer database, we identified 720 patients who underwent NSS from 1 January 2000 until 31 December 2010 and identified eleven (1.5%) patients with a delayed US.
• ? Patient and tumour characteristics were reviewed.

RESULTS

• ? Median (range) tumour size and RENAL nephrometry score was 4.1 (2–7.2) cm and 10p (4–11p), respectively.
• ? There were eight of 10 solitary tumours (80%) located in the lower or mid‐pole of the kidney.
• ? There were eight of 11 patients with delayed US (72.7%) who experienced a postoperative urinary leak.
• ? There were two of 11 (18.2%) patients who experienced a postoperative retroperitoneal haemorrhage, with one of these patients requiring selective embolization.
• ? All US were in the upper third of the ureter and were diagnosed at a minimum of 10 weeks postoperatively (median 154 days, range 70–400 days).

CONCLUSIONS

• ? US formation is an uncommon and under‐reported event after complex NSS.
• ? Risk factors appear to include tumour complexity, imperative indications, mid‐ or lower pole location, postoperative urinary leak and haemorrhage.
• ? Although uncommon, postoperative US can occur after NSS for complex renal masses, necessitating patient counselling and diligent postoperative surveillance.

     

External validation of a model for tailoring the operative approach to minimally invasive partial nephrectomy

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? In comparison to open partial nephrectomy, renal hypothermia is not routinely performed when completed laparoscopically, making warm ischemia time (WIT) a critical issue. Given that the duration of renal ischemia is the strongest modifiable surgical risk factor for decreased renal function after partial nephrectomy, efforts to limit ischemic time are of paramount importance. One technical modification during laparoscopic partial nephrectomy (previously reported by Weizer et al.), sought to simplify the technique by obviating the need for hilar clamping and/or suturing based on preoperative tumour characteristics. Ideally this modification would allow the surgeon to significantly decrease or even eliminate WIT in selected cases without compromising oncological efficacy or adversely impact treatment outcomes. This study adds to the growing body of literature that seeks to minimize WIT during minimally‐invasive partial nephrectomy (MIPN). We feel that this approach, which simplifies a technically challenging operation while maintaining a low rate of adverse events and positive surgical margins, could potentially have MIPN applied more broadly throughout the urological community and ultimately decrease the preference for radical nephrectomy in cases of T1a tumours.

OBJECTIVE

• ? To externally validate and modify an existing technical strategy of prospectively tailoring one’s operative approach to minimally invasive partial nephrectomy (MIPN).

PATIENTS AND METHODS

• ? We prospectively applied the model used in this strategy to evaluate 44 consecutive patients who underwent MIPN between August 2006 and August 2008.
• ? Patients were divided into four groups according to tumour depth of penetration or entry into the collecting system. Group 1 (n= 9, 20%) underwent MIPN without clamping the renal hilum or parenchymal suturing. Group 2 (n= 2, 5%) underwent clamping but not suturing. Group 3 (n= 21, 48%) underwent clamping and suturing. Group 4 (n= 12, 27%) underwent clamping, renal sinus reconstruction and suturing.
• ? We then assessed the peri‐ and postoperative outcomes, tumour histopathology and complications for each group.

RESULTS

• ? All patients had successful procedures according to the strategic model.
• ? The mean operative time was 246 (105–420) min and the mean estimated blood loss was 177 (25–1000) mL. When patients were stratified by clamping vs no clamping, the only significant variables between the two groups were operative time (245 vs 203 min) and pathology (83% vs 44% malignant).
• ? Six patients in the clamping group had postoperative complications (three had delayed bleeding, two had pneumonia, and one had infected urinoma) vs one patient in the no‐clamping group who had prolonged ileus (P > 0.05).
• ? Mean hospital stay was comparable in both groups (2.6 vs 3 days).

CONCLUSION

• ? Minimally invasive partial nephrectomy can be tailored according to tumour location, avoiding unnecessary clamping and/or suturing of the kidney without negatively affecting treatment outcomes.

     

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.