Predicting positive surgical margins in partial nephrectomy: A prospective multicentre observational study (the RECORd 2 project)

Hospital Volume as a Determinant of Outcomes After Partial Nephrectomy: A Systematic Review by the European Association of Urology Renal Cell Carcinoma Guidelines Panel

The influence of surgical volume on partial nephrectomy (PN) outcomes is a subject of debate. The European Association of Urology (EAU) renal cell carcinoma (RCC) guideline panel performed a protocol-driven systematic review of the association between hospital volume (HV) and oncological, functional, and complication outcomes following PN for RCC. The intervention was PN performed in a higher-volume hospital (defined according to the number of procedures per unit time) and the comparator was PN performed in a lower-volume hospital. Ten studies involving a total of 106 569 patients were included in the review. Higher HV was associated with lower complication rates, shorter length of stay, lower positive surgical margin rates, and lower transfusion rates. For six studies, multivariable analyses showed that low HV was an independent risk factor for inpatient complications, PSM presence, longer LOS, and failure to achieve a trifecta of no complications, warm ischemia time <25 min, and negative surgical margins. Most studies were judged to have high risk of bias. The available evidence suggests a potential association between higher HV and better PN outcomes in RCC. The EAU RCC guidelines panel encourages the development and rigorous evaluation of indicators of surgery quality in RCC to better inform the designation of high-quality centers within models of centralized care.

Perioperative and Mid-Term Oncological and Functional Outcomes After Partial Nephrectomy for Entirely Endophytic Renal Tumors: A Prospective Multicenter Observational Study (The RECORD2 Project)

BACKGROUND AND OBJECTIVES

Totally endophytic renal tumors are a unique subset that pose significant technical challenges during partial nephrectomy (PN). The aim of this study was to evaluate the perioperative, oncologic, and functional outcomes of PN in this particular setting.

MATERIALS AND METHODS

We retrospectively evaluated 4151 patients who had surgical treatment for renal tumors between January 2013 and December 2016 at 26 urological Italian Centers (RECORD 2 project). Only patients treated with PN for entirely endophytic renal tumor were considered for final analyses.

RESULTS

A total of 211 patients were included, with a median PADUA score of 10 (IQR 9-11). Open, laparoscopic, and robotic approaches were used in 94 (44.5%), 52 (24.6%), and 65 (30.8%) cases, respectively. While surgical approach did not impact complication rates, robotic PN had significantly lower median blood loss (100 vs. 185 vs. 175 cc, p = 0.04) and shorter operative time (126 vs. 140 vs. 160 min, p = 0.01) compared to open and laparoscopic PN. At a median follow-up of 36.3 months (IQR 21.9-49.2), recurrence-free survival was 93.8%. Median %eGFR drop at 24 months was 12.1 (IQR 5.1-21.9), with significant eGFR loss (≥25%) in 36 (17.1%) patients. The robotic approach was associated with a lower %eGFR drop at 1-month and 1-year evaluations, but the benefit diminished at 24 months. Multivariate analysis showed age and open surgery as independent predictors of renal function loss at 1 month and Trifecta failure.

CONCLUSIONS

The conservative management of entirely endophytic renal tumors is associated with favorable functional and oncologic outcomes. Whenever technically feasible, conservative surgery should be prioritized to optimize early renal function recovery.

Surgeon Skill and Perioperative Outcomes in Robot-Assisted Partial Nephrectomy

Importance

Technical skill in complex surgical procedures may affect clinical outcomes, and there is growing interest in understanding the clinical implications of surgeon proficiency levels.

Objectives

To determine whether surgeon scores representing technical skills of robot-assisted kidney surgery are associated with patient outcomes.

Design, Setting, and Participants

This quality improvement study included 10 urological surgeons participating in a surgical collaborative in Michigan from July 2021 to September 2022. Each surgeon submitted up to 7 videos of themselves performing robot-assisted partial nephrectomy. Videos were segmented into 6 key steps, yielding 127 video clips for analysis. Each video clip was deidentified and distributed to at least 3 of the 24 blinded peer surgeons from the collaborative who also perform robot-assisted partial nephrectomy. Reviewers rated technical skill and provided written feedback. Statistical analysis was performed from May 2023 to January 2024.

Main Outcomes and Measures

Reviewers scored each video clip using a validated instrument to assess technical skill for partial nephrectomy on a scale of 1 to 5 (higher scores indicating greater skill). For all submitting surgeons, outcomes from a clinical registry were assessed for length of stay (LOS) greater than 3 days, estimated blood loss (EBL) greater than 500 mL, warm ischemia time (WIT) greater than 30 minutes, positive surgical margin (PSM), 30-day emergency department (ED) visits, and 30-day readmission.

Results

Among the 27 unique surgeons who participated in this study as reviewers and/or individuals performing the procedures, 3 (11%) were female, and the median age was 47 (IQR, 39-52) years. Risk-adjusted outcomes were associated with scores representing surgeon skills. The overall performance score ranged from 3.5 to 4.7 points with a mean (SD) of 4.1 (0.4) points. Greater skill was correlated with significantly lower rates of LOS greater than 3 days (-6.8% [95% CI, -8.3% to -5.2%]), EBL greater than 500 mL (-2.6% [95% CI, -3.0% to -2.1%]), PSM (-8.2% [95% CI, -9.2% to -7.2%]), ED visits (-3.9% [95% CI, -5.0% to -2.8%]), and readmissions (-5.7% [95% CI, -6.9% to -4.6%]) (P < .001 for all). Higher overall score was also associated with higher partial nephrectomy volume (β coefficient, 11.4 [95% CI, 10.0-12.7]; P < .001).

Conclusions and Relevance

In this quality improvement study on video-based evaluation of robot-assisted partial nephrectomy, higher technical skill was associated with lower rates of adverse clinical outcomes. These findings suggest that video-based evaluation plays a role in assessing surgical skill and can be used in quality improvement initiatives to improve patient care.

Comparing the outcomes of open, laparoscopic and robot-assisted partial nephrectomy: a network meta-analysis

OBJECTIVE

To perform a systematic review and network meta-analysis (NMA) to determine the advantages and disadvantages of open (OPN), laparoscopic (LPN), and robot-assisted partial nephrectomy (RAPN) with particular attention to intraoperative, immediate postoperative, as well as longer-term functional and oncological outcomes.

METHODS

A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-NMA guidelines. Binary data were compared using odds ratios (ORs). Mean differences (MDs) were used for continuous variables. ORs and MDs were extracted from the articles to compare the efficacy of the various surgical approaches. Statistical validity is guaranteed when the 95% credible interval does not include 1.

RESULTS

In total, there were 31 studies included in the NMA with a combined 7869 patients. Of these, 33.7% (2651/7869) underwent OPN, 20.8% (1636/7869) LPN, and 45.5% (3582/7689) RAPN. There was no difference for either LPN or RAPN as compared to OPN in ischaemia time, intraoperative complications, positive surgical margins, operative time or trifecta rate. The estimated blood loss (EBL), postoperative complications and length of stay were all significantly reduced in RAPN when compared with OPN. The outcomes of RAPN and LPN were largely similar except the significantly reduced EBL in RAPN.

CONCLUSION

This systematic review and NMA suggests that RAPN is the preferable operative approach for patients undergoing surgery for lower-staged RCC.

Prognostic features of upstaged pT3a renal tumors with fat invasion after robot-assisted partial nephrectomy: is it time for a new subclassification?

INTRODUCTION

The clinical management of pT3a pathologic-upstaged renal cell carcinoma (RCC) patients is actually controversial. Aim of this study was i) to assess the impact of pT3a upstaging on oncologic outcomes after robot-assisted partial nephrectomy (RAPN) for cT1-T2 RCC; ii) to explore clinical and surgical predictors of pT3a upstaging; iii) to evaluate the differential impact of perinephric fat invasion (PFI) or sinus fat invasion (SFI) on survival outcomes after RAPN in case of upstaged pT3a RCC.

MATERIALS AND METHODS

Clinical and surgical data from consecutive RCCs treated with RAPN in a single referral centre between January 2017 and June 2021 were prospectively collected and retrospectively reviewed. Pathological upstaging to pT3a tumors with fat invasion was further stratified in SFI or PFI. Uni- and multivariable analysis were fitted to explore clinical and surgical predictors of disease recurrence.

RESULTS

Overall, 1852 patients were enrolled and 179 (9.7%) with pT3a upstaging were found. Median age was 65 (IQR 56-73) years with a median BMI of 25.6 (23.6-29.0). At a median follow up of 26 (9-38) months, 76 (4.1%) patients showed disease recurrence. Multivariable analysis confirmed PADUA score ≥10 (OR 1.76, CI 95% 1.18-1.91, p = 0.001), age at surgery (OR 1.04, CI 95% 1.01-1.06, p = 0.01), clinical tumor diameter (OR 1.31, CI 95% 1.17-1.47, p = 0.001), tumor necrosis (OR 1.54, CI 95% 1.08-1.88, p = 0.001) and nucleolar grading ≥3 (OR 1.27, CI 95% 1.01-1.44, p = 0.001) as independent predictors of pT3a upstaging. Multivariate Cox regression model showed pathological sinus fat invasion as an independent predictor of disease recurrence (HR 3.43, CI 95% 1.51-7.77, p = 0.003) in pT3a upstaged group.

CONCLUSION

In pathologically upstaged pT3a RCCs, sinus fat invasion was confirmed as independent predictor of disease relapse. In this light, the definition of novel risk categories in the pT3a patients setting should be encouraged.

Positive surgical margin's impact on short-term oncological prognosis after robot-assisted partial nephrectomy (MARGINS study: UroCCR no 96)

The oncological impact of positive surgical margins (PSM) after robot-assisted partial nephrectomy (RAPN) is still under debate. We compared PSM and Negative Surgical Margins (NSM) in terms of recurrence-free survival (RFS), metastasis-free survival (MFS) and overall survival (OS) after RAPN, and we identified predictive factors of PSM. Multi-institutional study using the UroCCR database, which prospectively included 2166 RAPN between April 2010 and February 2021 (CNIL DR 2013-206; NCT03293563). Two groups were retrospectively compared: PSM versus NSM. Prognostic factors were assessed using Kaplan-Meyer curves with log-Rank test, cox hazard proportional risk model and logistic regression after univariate comparison. 136 patients had PSM (6.3%) and 2030 (93.7%) had NSM. During a median follow-up of 19 (9-36) months after RAPN, 160 (7.4%) recurrences were reported. Kaplan-Meier curves and analysis suggested that RFS, MFS and OS were not affected by a PSM (p = 0.68; 0.71; 0.88, respectively). In multivariate analysis predictors of PSM were a lower RENAL score (p = 0.001), longer warm ischemia time (WIT) (p = 0.003) and Chromophobe Renal Cell Carcinoma (chrRCC) (p = 0.043). This study found no impact of PSM on RFS, MFS or OS, and predictors of PSM were the RENAL score, WIT and chrRCC.

3D renal model for surgical planning of partial nephrectomy: A way to improve surgical outcomes

OBJECTIVE

to evaluate the impact of 3D model for a comprehensive assessment of surgical planning and quality of partial nephrectomy (PN).

MATERIALS AND METHODS

195 patients with cT1-T2 renal mass scheduled for PN were enrolled in two groups: Study Group (n= 100), including patients referred to PN with revision of both 2D computed tomography (CT) imaging and 3D model; Control group (n= 95), including patients referred to PN with revision of 2D CT imaging. Overall, 20 individuals were switched to radical nephrectomy (RN). The primary outcome was the impact of 3D models-based surgical planning on Trifecta achievement (defined as the contemporary absence of positive surgical margin, major complications and ≤30% postoperative eGFR reduction). The secondary outcome was the impact of 3D models on surgical planning of PN. Multivariate logistic regressions were used to identify predictors of selective clamping and Trifecta's achievement in patients treated with PN (n=175).

RESULTS

Overall, 73 (80.2%) patients in Study group and 53 (63.1%) patients in Control group achieved the Trifecta (p=0.01). The preoperative plan of arterial clamping was recorded as clampless, main artery and selective in 22 (24.2%), 22 (24.2%) and 47 (51.6%) cases in Study group vs. 31 (36.9%), 46 (54.8%) and 7 (8.3%) cases in Control group, respectively (p<0.001). At multivariate logistic regressions, the use of 3D model was found to be independent predictor of both selective or super-selective clamping and Trifecta's achievement.

CONCLUSION

3D-guided approach to PN increase the adoption of selective clamping and better predict the achievement of Trifecta.

Development and Validation of a Nomogram Predicting Intraoperative Adverse Events During Robot-assisted Partial Nephrectomy

BACKGROUND

Ability to predict the risk of intraoperative adverse events (IOAEs) for patients undergoing partial nephrectomy (PN) can be of great clinical significance.

OBJECTIVE

To develop and internally validate a preoperative nomogram predicting IOAEs for robot-assisted PN (RAPN).

DESIGN, SETTING, AND PARTICIPANTS

In this observational study, data for demographic, preoperative, and postoperative variables for patients who underwent RAPN were extracted from the Vattikuti Collective Quality Initiative (VCQI) database.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

IOAEs were defined as the occurrence of intraoperative surgical complications, blood transfusion, or conversion to open surgery/radical nephrectomy. Backward stepwise logistic regression analysis was used to identify predictors of IOAEs. The nomogram was validated using bootstrapping, the area under the receiver operating characteristic curve (AUC), and the goodness of fit. Decision curve analysis (DCA) was used to determine the clinical utility of the model.

RESULTS AND LIMITATIONS

Among the 2114 patients in the study cohort, IOAEs were noted in 158 (7.5%). Multivariable analysis identified five variables as independent predictors of IOAEs: RENAL nephrometry score (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.25); clinical tumor size (OR 1.01, 95% CI 1.001-1.024); PN indication as absolute versus elective (OR 3.9, 95% CI 2.6-5.7) and relative versus elective (OR 4.2, 95% CI 2.2-8); Charlson comorbidity index (OR 1.17, 95% CI 1.05-1.30); and multifocal tumors (OR 8.8, 95% CI 5.4-14.1). A nomogram was developed using these five variables. The model was internally valid on bootstrapping and goodness of fit. The AUC estimated was 0.76 (95% CI 0.72-0.80). DCA revealed that the model was clinically useful at threshold probabilities >5%. Limitations include the lack of external validation and selection bias.

CONCLUSIONS

We developed and internally validated a nomogram predicting IOAEs during RAPN.

PATIENT SUMMARY

We developed a preoperative model than can predict complications that might occur during robotic surgery for partial removal of a kidney. Tests showed that our model is fairly accurate and it could be useful in identifying patients with kidney cancer for whom this type of surgery is suitable.

Novel Volumetric and Morphological Parameters Derived from Three-dimensional Virtual Modeling to Improve Comprehension of Tumor's Anatomy in Patients with Renal Cancer

BACKGROUND

Three-dimensional (3D) models improve the comprehension of renal anatomy.

OBJECTIVE

To evaluate the impact of novel 3D-derived parameters, to predict surgical outcomes after robot-assisted partial nephrectomy (RAPN).

DESIGN, SETTING, AND PARTICIPANTS

Sixty-nine patients with cT1-T2 renal mass scheduled for RAPN were included. Three-dimensional virtual modeling was achieved from computed tomography. The following volumetric and morphological 3D parameters were calculated: V_T (volume of the tumor); V_T/V_K (ratio between tumor volume and kidney volume); CSA_3D (ie, contact surface area); UCS_3D (contact to the urinary collecting system); Tumor-Artery_3D: tumor's blood supply by tertiary segmental arteries (score = 1), secondary segmental artery (score = 2), or primary segmental/main renal artery (scoren = 3); S_T (tumor's sphericity); Conv_T (tumor's convexity); and Endophyticity_3D (ratio between the CSA_3D and the global tumor surface).

INTERVENTION

RAPN with a 3D model.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Three-dimensional parameters were compared between patients with and without complications. Univariate logistic regression was used to predict overall complications and type of clamping; linear regression was used to predict operative time, warm ischemia time, and estimated blood loss.

RESULTS AND LIMITATIONS

Overall, 11 (15%) individuals experienced overall complications (7.2% had Clavien ≥3 complications). Patients with urinary collecting system (UCS) involvement at 3D model (UCS_3D = 2), tumor with blood supply by primary or secondary segmentary arteries (Tumor-Artery_3D = 1 and 2), and high Endophyticity_3D values had significantly higher rates of overall complications (all p ≤ 0.03). At univariate analysis, UCS_3D, Tumor-Artery_3D, and Endophyticity_3D are significantly associated with overall complications; CSA_3D and Endophyticity_3D were associated with warm ischemia time; and CSA_3D was associated with selective clamping (all p ≤ 0.03). Sample size and the lack of interobserver variability are the main limits.

CONCLUSIONS

Three-dimensional modeling provides novel volumetric and morphological parameters to predict surgical outcomes after RAPN.

PATIENT SUMMARY

Novel morphological and volumetric parameters can be derived from a three-dimensional model to describe surgical complexity of renal mass and to predict surgical outcomes after robot-assisted partial nephrectomy.

Predictors of Positive Surgical Margins after Robot-Assisted Partial Nephrectomy for Localized Renal Tumors: Insights from a Large Multicenter International Prospective Observational Project (The Surface-Intermediate-Base Margin Score Consortium)

Background: To explore predictors of positive surgical margins (PSM) after robotic partial nephrectomy (PN) in a large multicenter international observational project, harnessing the Surface-Intermediate-Base (SIB) margin score to report the resection technique after PN in a standardized way. Methods: Data from consecutive patients with cT1-2N0M0 renal masses treated with PN from September 2014 to March 2015 at 16 tertiary referral centers and included in the SIB margin score International Consortium were prospectively collected. For the present study, only patients treated with robotic PN were included. Uni- and multivariable analysis were fitted to explore clinical and surgical predictors of PSMs after PN. Results: Overall, 289 patients were enrolled. Median (IQR) preoperative tumor size was 3.0 (2.3−4.2) cm and median (IQR) PADUA score was 8 (7−9). SIB scores of 0−2 (enucleation), 3−4 (enucleoresection) and 5 (resection) were reported in 53.3%, 27.3% and 19.4% of cases, respectively. A PSM was recorded in 18 (6.2%) patients. PSM rate was 4.5%, 11.4% and 3.6% in case of enucleation, enucleoresection and resection, respectively. Patients with PSMs had tumors with a higher rate of contact with the urinary collecting system (55.6% vs. 27.3%; p < 0.001) and a longer median warm ischemia time (22 vs. 16 min; p = 0.02) compared with patients with negative surgical margins, while no differences emerged between the two groups in terms of other tumor features (i.e., pathological diameter, PADUA score). In multivariable analysis, only enucleoresection (SIB score 3−4) versus enucleation (SIB score 0−2) was found to be an independent predictor of PSM at final pathology (HR: 2.68; 95% CI: 1.25−7.63; p = 0.04), while resection (SIB score 5) was not. Conclusions: In our experience, enucleoresection led to a higher risk of PSMs as compared to enucleation. Further studies are needed to assess the differential impacts of resection technique and surgeon’s experience on margin status after robotic PN.

Prognostic Factors for Localized Clear Cell Renal Cell Carcinoma and Their Application in Adjuvant Therapy

Simple Summary

Approximately one fifth of patients with newly diagnosed renal cell carcinoma (RCC) present with metastatic disease and over one third of the remaining patients with localized RCC will eventually have metastases spread to distant sites after complete resection of the primary tumor in the kidney. Usually, disease recurrence is observed within the first five years of follow-up, but late recurrences after five years are seen in up to 10% of patients. Despite novel biomarkers, simple histopathological factors, such as tumor size, tumor grade, and tumor extension into the blood vessels or beyond the kidney, are still valid features in predicting the risk of disease recurrence after surgery. The optimal set of prognostic factors remains unclear. The results from ongoing placebo-controlled adjuvant therapy trials may elucidate prognostic features that help to define high-risk patients for disease recurrence.

Abstract

Approximately 20% of patients with renal cell carcinoma (RCC) present with primarily metastatic disease and over 30% of patients with localized RCC will develop distant metastases later, after complete resection of the primary tumor. Accurate postoperative prognostic models are essential for designing personalized surveillance programs, as well as for designing adjuvant therapy and trials. Several clinical and histopathological prognostic factors have been identified and adopted into prognostic algorithms to assess the individual risk for disease recurrence after radical or partial nephrectomy. However, the prediction accuracy of current prognostic models has been studied in retrospective patient cohorts and the optimal set of prognostic features remains unclear. In addition to traditional histopathological prognostic factors, novel biomarkers, such as gene expression profiles and circulating tumor DNA, are extensively studied to supplement existing prognostic algorithms to improve their prediction accuracy. Here, we aim to give an overview of existing prognostic features and prediction models for localized postoperative clear cell RCC and discuss their role in the adjuvant therapy trials. The results of ongoing placebo-controlled adjuvant therapy trials may elucidate prognostic factors and biomarkers that help to define patients at high risk for disease recurrence.

Percutaneous ablation or minimally invasive partial nephrectomy for cT1a renal masses? A propensity score-matched analysis

OBJECTIVE

Local tumor ablation to treat small renal mass is increasing. The aim of the present study was to compare oncologic outcomes among patients with T1 renal mass treated with partial nephrectomy and local tumor ablation.

METHODS

To reduce the inherent differences between patients undergoing laparoscopic or robot-assisted partial nephrectomy (n = 405) and local tumor ablation (n = 137), we used a 1:1 propensity score-matched analysis. Local tumor ablation consisted of radiofrequency ablation and cryoablation. Disease-free survival, overall survival and other causes mortality-free survival rates were estimated using the Kaplan-Meier method. Multivariable logistic regression and competing-risk regression models were used to identify predictors of complications, recurrence and other causes mortality, respectively.

RESULTS

Partial nephrectomy had higher disease-free survival estimates, as compared with local tumor ablation (92.8% vs 80.4% at 5 years, P = 0.02), with no significant difference between radiofrequency ablation and cryoablation (P = 0.9). Ablation showed comparable overall survival estimates to partial nephrectomy (91% vs 95.8% at 5 years, P = 0.6). The 5-year recurrence rates were 7.9% versus 23.8% for patients aged ≤70 years, and 2.5% versus 11.9% for patients aged >70 years treated with partial nephrectomy and ablation, respectively; the 5-year other causes mortality rates were 0% and 2.2% for patients treated with partial nephrectomy and ablation aged ≤70 years, and 3% versus 10.9% for patients aged >70 years treated with partial nephrectomy and ablation, respectively. At multivariable analysis, ablation was associated with fewer complications (odds ratio 0.41; P = 0.01). At competing risks analysis, age (hazard ratio 0.96) and ablation (hazard ratio 4.56) were independent predictors of disease recurrence (all P ≤ 0.008).

CONCLUSIONS

Local tumor ablation showed a higher risk of recurrence and lower risk of complications compared with partial nephrectomy, with comparable overall survival rates.

Outcomes in robot-assisted partial nephrectomy for imperative vs elective indications

OBJECTIVES

To assess and compare peri-operative outcomes of patients undergoing robot-assisted partial nephrectomy (RAPN) for imperative vs elective indications.

PATIENT AND METHODS

We retrospectively reviewed a multinational database of 3802 adults who underwent RAPN for elective and imperative indications. Laparoscopic or open partial nephrectomy (PN) were excluded. Baseline data for age, gender, body mass index, American Society of Anaesthesiologists score and PADUA score were examined. Patients undergoing RAPN for an imperative indication were matched to those having surgery for an elective indication using propensity scores in a 1:3 ratio. Primary outcomes included organ ischaemic time, operating time, estimated blood loss (EBL), rate of blood transfusions, Clavien-Dindo complications, conversion to radical nephrectomy (RN) and positive surgical margin (PSM) status.

RESULTS

After propensity-score matching for baseline variables, a total of 304 patients (76 imperative vs 228 elective indications) were included in the final analysis. No significant differences were found between groups for ischaemia time (19.9 vs 19.8 min; P = 0.94), operating time (186 vs 180 min; P = 0.55), EBL (217 vs 190 mL; P = 0.43), rate of blood transfusions (2.7% vs 3.7%; P = 0.51), or Clavien-Dindo complications (P = 0.31). A 38.6% (SD 47.9) decrease in Day-1 postoperative estimated glomerular filtration rate was observed in the imperative indication group and an 11.3% (SD 45.1) decrease was observed in the elective indication group (P < 0.005). There were no recorded cases of permanent or temporary dialysis. There were no conversions to RN in the imperative group, and seven conversions (5.6%) in the elective group (P = 0.69). PSMs were seen in 1.4% (1/76) of the imperative group and in 3.3% of the elective group (7/228; P = 0.69).

CONCLUSION

We conclude that RAPN is feasible and safe for imperative indications and demonstrates similar outcomes to those achieved for elective indications.

Identification of an m6A-Related lncRNA Signature for Predicting the Prognosis in Patients With Kidney Renal Clear Cell Carcinoma

Purpose

This study aimed to construct an m6A-related long non-coding RNAs (lncRNAs) signature to accurately predict the prognosis of kidney clear cell carcinoma (KIRC) patients using data obtained from The Cancer Genome Atlas (TCGA) database.

Methods

The KIRC patient data were downloaded from TCGA database and m6A-related genes were obtained from published articles. Pearson correlation analysis was implemented to identify m6A-related lncRNAs. Univariate, Lasso, and multivariate Cox regression analyses were used to identifying prognostic risk-associated lncRNAs. Five lncRNAs were identified and used to construct a prognostic signature in training set. Kaplan-Meier curves and receiver operating characteristic (ROC) curves were applied to evaluate reliability and sensitivity of the signature in testing set and overall set, respectively. A prognostic nomogram was established to predict the probable 1-, 3-, and 5-year overall survival of KIRC patients quantitatively. GSEA was performed to explore the potential biological processes and cellular pathways. Besides, the lncRNA/miRNA/mRNA ceRNA network and PPI network were constructed based on weighted gene co-expression network analysis (WGCNA). Functional Enrichment Analysis was used to identify the biological functions of m6A-related lncRNAs.

Results

We constructed and verified an m6A-related lncRNAs prognostic signature of KIRC patients in TCGA database. We confirmed that the survival rates of KIRC patients with high-risk subgroup were significantly poorer than those with low-risk subgroup in the training set and testing set. ROC curves indicated that the prognostic signature had a reliable predictive capability in the training set (AUC = 0.802) and testing set (AUC = 0.725), respectively. Also, we established a prognostic nomogram with a high C-index and accomplished good prediction accuracy. The lncRNA/miRNA/mRNA ceRNA network and PPI network, as well as functional enrichment analysis provided us with new ways to search for potential biological functions.

Conclusions

We constructed an m6A-related lncRNAs prognostic signature which could accurately predict the prognosis of KIRC patients.

Robot-assisted partial nephrectomy for high-complexity tumors (PADUA score ≥10): Perioperative, long-term functional and oncologic outcomes

OBJECTIVES

To evaluate the safety and efficacy, and long-term functional and oncologic outcomes of robot-assisted partial nephrectomy in high-complexity tumors.

METHODS

Data of 155 patients with a high-complexity tumor (PADUA score ≥10) were reviewed. Trifecta achievement, intra-, perioperative, functional, and oncologic outcomes were analyzed and compared between patients with increasing complexity.

RESULTS

Of the 155 patients, 65 (41.9%) patients had a PADUA score of 10, 55 (35.5%) had a PADUA score of 11, and 35 (22.6%) had a PADUA score of 12-13, respectively. The median (interquartile range) operative time, warm ischemia time and estimated blood loss were 150 min (112-186 min), 26 min (23-32 min) and 250 mL (100-500 mL), respectively. Postoperatively, complications occurred in 25 (16.1%) patients, and positive surgical margins in 15 (10.5%) patients. Trifecta was achieved in 67 (43.2%) patients. At a median follow-up period of 58 months, the median estimated glomerular filtration rate preservation was 87% (78-110), and 12 (7.7%) patients developed new-onset chronic kidney disease. Recurrence-free survival and overall survival rates were 93.6% and 96.7%, respectively. Positive surgical margins were statistically different between the groups of PADUA score 10, 11 and 12-13 (P = 0.017), whereas functional and oncologic outcomes were similar. In multivariate logistic regression analysis, increasing tumor size (odds ratio 1.48, 95% confidence interval 1.21-1.87; P < 0.001) and the American Society of Anesthesiologists score 2/3 (odds ratio 0.48, 95% confidence interval 0.24-0.96; P = 0.041) were independent predictors of trifecta failure.

CONCLUSIONS

Robot-assisted partial nephrectomy is a safe and effective treatment for high-complexity tumors providing excellent long-term functional and oncologic outcomes.

Is partial nephrectomy safe and effective in the setting of frail comorbid patients affected by renal cell carcinoma? Insights from the RECORD 2 multicentre prospective study

BACKGROUND

To investigate the perioperative and morbidity outcomes after partial nephrectomy (PN) in patients with short life expectancy (SLE) (≥95% 10-year expected mortality (10y-EM)), to assess the main predictors of outcomes in this population and to compare these results with those of a group at the opposite upper range with long LE (LLE, ≤5% 10y-EM) relying on a multicenter Italian prospective registry of kidney surgery (the RECORD 2 project).

METHODS

Clinical data of 4,325 patients undergone kidney surgery were collected at 26 urological Italian Centers from 2013 to 2016. SLE was defined as a ≥95% 10y-EM (assessed using the age-adjusted Charlson comorbidity index [CCI]). A multivariable logistic regression for overall postoperative complications, acute kidney injury (AKI), positive surgical margins (SM) and ∆ estimated glomerular filtration rate (eGFR) ≥25% at 2 years from surgery was performed in patients with SLE including clinically relevant variables. Adjusted outcomes reported as mean (SD) of the 2 groups were generated using separate multivariable logistic regression models and compared.

RESULTS

Overall, 559 patients with SLE were selected. Patients had an ASA score ≥3 in 58.4% of cases. A clinical T1a, T1b, and T2 stage was found in 412 (74.5%), 124 (22.4%), and 17 (3.1%) patients. The median PADUA score was 7 (6-8). Surgical and medical postoperative complication rates were registered in 14.8% and 6% cases. Postoperative AKI was reported in 27.3% cases, positive surgical margins (PSM) in 9.3% cases. In this subgroup of patients, ASA score, cerebrovascular disease, surgery in low volume centers, and open surgery were independent predictors of overall complications. ASA and PADUA scores, renal clamping, resection technique and lower eGFR at baseline were independent predictors of AKI. PADUA score, open approach and resection technique were independent predictors of PSM. Cardiovascular disease, hilar clamping, and resection technique were independent predictors of eGFR decrease >25% at 2 years from surgery. Patients with SLE were compared with those with LLE (n = 302). All analyzed parameters at baseline were significantly different among the groups with the exception of cancer laterality. After adjusting for several clinical variables, the SLE group had a significantly higher risk rate of adjusted overall postoperative complication rate compared to the LLE group (20.6% ± 0.36 vs. 9.9% ± 0.65, P < 0.0001), while the overall intraoperative complications (4.1% ±0.13 vs. 2.3% ± 0.23), overall postoperative major complications (3.8% ± 0.09 vs. 1.9% ± 0.14) adjusted AKI (24.2% ± 0.37 vs. 22.6% ± 0.92), positive surgical margins (8% ± 0.22 vs. 6.4% ± 0.49), and 2-year RF loss (13.4% ± 0.17 vs. 12.4% ± 0.74).

CONCLUSION

In selected patients with SLE, PN is feasible with an acceptable safety profile that is overall comparable to patients with no LE limitations. While a robotic approach and surgery performed in high volume centers could reduce the risk of complications, an off-clamp approach and a SE surgical technique may decrease the risk of postoperative AKI and of longer term eGFR decrease.