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

Impact of worsening surgically induced chronic kidney disease (CKD-S) in preoperative CKD-naïve patients on survival in renal cell carcinoma

OBJECTIVES

To evaluate effects of worsening surgically induced chronic kidney disease (CKD-S) on oncological and non-oncological survival outcomes in renal cell carcinoma (RCC).

PATIENTS AND METHODS

We performed a retrospective analysis of patients who underwent partial (PN) or radical nephrectomy (RN) and were free of preoperative CKD (estimated glomerular filtration rate [eGFR] ≥60 mL/min/1.73 m² ). Patients were stratified by CKD stage at last follow-up: no CKD-S (eGFR ≥60 mL/min/1.73 m² ), de novo CKD-S 3a (eGFR 45-59 mL/min/1.73 m² ), CKD-S 3b (eGFR <45 and ≥30 mL/min/1.73 m² ) and CKD-S 4 (eGFR <30 and ≥15 mL/min/1.73 m² ). The primary outcome was all-cause mortality (ACM). Secondary outcomes included non-cancer mortality (NCM), cancer-specific mortality (CSM) and de novo CKD-S Stage 3/4. Multivariable analysis (MVA) was utilised to identify risk factors for outcomes. Kaplan-Meier analysis (KMA) was utilised to evaluate overall (OS), non-cancer (NCS), and cancer-specific survival with respect to CKD-S categories.

RESULTS

We analysed 3239 patients. The mean preoperative and last-follow-up eGFRs were 87.4 and 69.5 mL/min/1.73 m² , respectively. On last follow-up, 57.9% (n = 1876) had no CKD-S, 18.7% (n = 606) had CKD-S 3a, 15.1% (n = 489) had CKD-S 3b and 8.3% (n = 268) had CKD-S 4. On MVA, de novo CKD-S 3b and 4 were independently associated with ACM (hazard ratios [HRs] 1.3-2.1, P = 0.003-0.001) and NCM (HRs 1.5-2.8, P = 0.021-0.001), but not CSM (P = 0.219-0.909); de novo CKD-S 3a was not predictive for any mortality outcomes (P = 0.102-0.81). RN was independently associated with CKD-S 3-4 (HRs 1.78-1.99, P < 0.001-0.035). Comparing no CKD-S, CKD-S 3a, CKD-S 3b and CKD-S 4, KMA demonstrated worsening outcomes with progressive CKD-S stage: 5-year OS 84% vs 78% vs 71% vs 60% (P < 0.001) and 5-year NCS 93% vs 87% vs 83% vs 72% (P < 0.001).

CONCLUSION

Development of CKD-S Stage 3b and 4, but not 3a, was associated with worsened ACM and NCM. The decision to proceed with nephron preservation via PN should be individualised based on oncological risk and risk of functional decline to CKD-S 3b or 4, and not CKD-S 3a.

Partial Nephrectomy Versus Radical Nephrectomy for Endophytic Renal Tumors: Comparison of Operative, Functional, and Oncological Outcomes by Propensity Score Matching Analysis

Purpose

The study aimed to compare operative, functional, and oncological outcomes between partial nephrectomy (PN) and radical nephrectomy (RN) for entophytic renal tumors (ERTs) by propensity score matching (PSM) analysis.

Methods

A total of 228 patients with ERTs who underwent PN or RN between August 2014 and December 2021 were assessed. A PSM in a 1:1 ratio was conducted to balance the differences between groups. Perioperative characteristics, renal functional, and oncological outcomes were compared between groups. Univariate and multivariate logistic and Cox proportional hazard regression analyses were used to determine the predictors of functional and survival outcomes.

Results

After PSM, 136 cases were matched to the PN group (n = 68) and the RN group (n = 68). Patients who underwent RN had shorter OT, less EBL, and lower high-grade complications (all p <0.05) relative to those who underwent PN. However, better perseveration of renal function was observed in the PN group, which was reflected in 48-h postoperative AKI (44.1% vs. 70.6%, p = 0.002), 1-year postoperative 90% eGFR preservation (45.6% vs. 22.1%, p = 0.004), and new-onset CKD Stage ≥III at last follow-up (2.9% vs. 29.4%, p <0.001). RN was the independent factor of short-term (OR, 2.812; 95% CI, 1.369–5.778; p = 0.005) and long-term renal function decline (OR, 10.242; 95% CI, 2.175–48.240; p = 0.003). Furthermore, PN resulted in a better OS and similar PFS and CSS as compared to RN (p = 0.042, 0.15, and 0.21, respectively). RN (OR, 7.361; 95% CI, 1.143–47.423; p = 0.036) and pT3 stage (OR, 4.241; 95% CI, 1.079–16.664; p = 0.039) were independent predictors of overall mortality.

Conclusion

Among patients with ERTs, although the PN group showed a higher incidence of high-grade complications than RN, when technically feasible and with experienced surgeons, PN is recommended for better preservation of renal function, longer OS, and similar oncological outcomes.

Retroperitoneal laparoscopic partial versus radical nephrectomy for large (≥ 4 cm) and anatomically complex renal tumors: A propensity score matching study

INTRODUCTION

To assess the safety and efficiency of retroperitoneal laparoscopic partial nephrectomy (RLPN) and retroperitoneal laparoscopic radical nephrectomy (RLRN) for large (≥4 cm) renal tumors with a RENAL nephrometry score ≥7.

MATERIALS AND METHODS

We retrospectively identified and analyzed the data of 254 patients who underwent RLPN or RLRN for large (≥4 cm) and anatomically complex renal tumors between 2008 and 2017. Propensity score matching (PSM) (1:1) method was conducted to adjust for preoperative clinical characteristics. Preoperative, renal functional, and oncological outcomes were compared.

RESULTS

Finally, no significant differences in the baseline characteristics existed between the two groups after PSM. Within the well-balanced matched cohort, longer operating time (OT) and higher estimated blood loss (EBL) were found in RLPN group (p = 0.015 and p = 0.019, respectively), and RLPN trended to protect renal function better at a higher risk of low-grade complications (-10.9 vs -16.8 ml/min, p = 0.001; 23.0% vs 10.8%, p = 0.048, respectively). The patients in the RLPN group had a better overall survival (OS) than those in RLRN group, but cancer-specific survival and progression-free survival didn't differ significantly between the two groups.

CONCLUSION

For patients with large (≥4 cm) and anatomically complex renal tumors, RLPN by highly experienced hands has an evident tendency to a better protection of renal function and a longer OS without waiving oncological control in comparison with RLRN, but at the expense of longer OT, a higher EBL and a higher risk of low-grade complications.

Partial nephrectomy versus radical nephrectomy for clinical localised renal masses

BACKGROUND

Partial nephrectomy and radical nephrectomy are the relevant surgical therapy options for localised renal cell carcinoma. However, debate regarding the effects of these surgical approaches continues and it is important to identify and summarise high-quality studies to make surgical treatment recommendations.

OBJECTIVES

To assess the effects of partial nephrectomy compared with radical nephrectomy for clinically localised renal cell carcinoma.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PubMed, Embase, Web of Science, BIOSIS, LILACS, Scopus, two trial registries and abstracts from three major conferences to 24 February 2017, together with reference lists; and contacted selected experts in the field.

SELECTION CRITERIA

We included a randomised controlled trial comparing partial and radical nephrectomy for participants with small renal masses.

DATA COLLECTION AND ANALYSIS

One review author screened all of the titles and abstracts; only citations that were clearly irrelevant were excluded at this stage. Next, two review authors independently assessed full-text reports, identified relevant studies, evaluated the eligibility of the studies for inclusion, assessed trial quality and extracted data. The update of the literature search was performed by two independent review authors. We used Review Manager 5 for data synthesis and data analyses.

MAIN RESULTS

We identified one randomised controlled trial including 541 participants that compared partial nephrectomy to radical nephrectomy. The median follow-up was 9.3 years.Based on low quality evidence, we found that time-to-death of any cause was decreased using partial nephrectomy (HR 1.50, 95% CI 1.03 to 2.18). This corresponds to 79 more deaths (5 more to 173 more) per 1000. Also based on low quality evidence, we found no difference in serious adverse events (RR 2.04, 95% CI 0.19 to 22.34). Findings are consistent with 4 more surgery-related deaths (3 fewer to 78 more) per 1000.Based on low quality evidence, we found no difference in time-to-recurrence (HR 1.37, 95% CI 0.58 to 3.24). This corresponds to 12 more recurrences (14 fewer to 70 more) per 1000. Due to the nature of reporting, we were unable to analyse overall rates for immediate and long-term adverse events. We found no evidence on haemodialysis or quality of life.Reasons for downgrading related to study limitations (lack of blinding, cross-over), imprecision and indirectness (a substantial proportion of patients were ultimately found not to have a malignant tumour). Based on the finding of a single trial, we were unable to conduct any subgroup or sensitivity analyses.

AUTHORS' CONCLUSIONS

Partial nephrectomy may be associated with a decreased time-to-death of any cause. With regards to surgery-related mortality, cancer-specific survival and time-to-recurrence, partial nephrectomy appears to result in little to no difference.

Collaborative Review of Risk Benefit Trade-offs Between Partial and Radical Nephrectomy in the Management of Anatomically Complex Renal Masses

BACKGROUND

While partial nephrectomy (PN) is the recommended treatment for many small renal masses, anatomically complex tumors necessitate a clear understanding of the potential risks and benefits of PN and radical nephrectomy (RN).

OBJECTIVE

To critically review the comparative effectiveness evidence of PN versus RN; to describe key trade-offs involved in this treatment decision; and to highlight gaps in the current literature.

EVIDENCE ACQUISITION

A collaborative critical review of the medical literature was conducted.

EVIDENCE SYNTHESIS

Patients who undergo PN for an anatomically complex or large mass may be exposed to perioperative and potential oncologic risks that could be avoided if RN were performed, while patients who undergo RN may forgo long-term benefits of renal preservation. Decision-making regarding the optimal treatment with PN or RN among patients with anatomically complex or large renal mass is highly nuanced and must balance the risks and benefits of each approach. Currently, high-quality evidence on comparative effectiveness is sparse. Retrospective comparisons are plagued by selection biases, while the one existing prospective randomized trial, albeit imperfect, suggests that nephron-sparing surgery may not benefit all patients.

CONCLUSIONS

For anatomically complex tumors, PN preserves renal parenchyma but may expose patients to higher perioperative risks than RN. The risks and benefits of each surgical approach must be better objectified for identification of patients most suitable for complex PN. A prospective randomized trial is warranted and would help in directing patient counseling.

PATIENT SUMMARY

Treatment decisions for complex renal masses require shared decision-making regarding the risk trade-offs between partial and radical nephrectomy.

Emerging surgical treatments for renal cell carcinoma

Treatment of renal cell carcinoma has evolved considerably over the last few years. While total nephrectomy is necessary at times, nephron-sparing surgery, with a goal of renal function preservation, should always be considered. Although open partial nephrectomy is considered the gold standard approach for nephron-sparing surgery, laparoscopic- or robotic-assisted techniques allow urologists to perform renal surgery less invasively, with excellent long-term oncological outcomes. Cryotherapy and radiofrequency ablation are less invasive management approaches for carefully selected patients with small renal masses. Active surveillance should be considered in elderly or patients who are unfit for surgery. Ultimately, the method chosen for management of a renal mass is an informed decision made by the physician and patient.

Evaluation of national trends in the utilization of partial nephrectomy in relation to the publication of the American Urologic Association guidelines for the management of clinical T1 renal masses

Background

Partial nephrectomy has been underutilized in the United States. We investigated national trends in partial nephrectomy (PN) utilization before and after publication of the American Urological Association (AUA) Practice Guideline for management of the clinical T1 renal mass.

Methods

We identified adult patients who underwent radical (RN) or PN from November 2007 to October 2011 in the Nationwide Inpatient Sample (NIS). PN prevalence was calculated prior to (11/2007-10/2009) and after Guidelines publication (11/2009-10/2011) and compared the rate of change by linear regression. We also examined the nephrectomy trends in patients with chronic kidney disease (CKD). Statistical analysis included linear regression to determine point-prevalence of PN rates in CKD patients and logistic regression to identify variables associated with PN.

Results

During the study period, 30,944 patients underwent PN and 64,767 RN. The prevalence PN increased from 28.9% in the years prior to guideline release to 35.3% in the years following guideline release with an adjusted odds ratio (OR) of 1.24 (CI 1.01–1.54; p = 0.049). The rate of PN significantly increased throughout the study period (R² 0.15, p = 0.006): however, the rate of change was not increased after the guidelines. (p = 0.46). Overall rate of PN in patients with CKD did not increase over time (R² 0.0007, p = 0.99).

Conclusion

We noted a 6.4% absolute increase in PN after release of the AUA guidelines on clinical T1 renal mass was published; however, the rate of increase was not likely associated with guideline release. The rate of PN performed is increasing; however, further investigation regarding medical decision-making surrounding PN is needed.

Impact of renal surgery for cortical neoplasms on lipid metabolism

OBJECTIVE

To examine the incidence of and risk factors for development of hyperlipidaemia in patients undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for renal cortical neoplasms, as hyperlipidaemia is a major source of morbidity in chronic kidney disease (CKD).

PATIENTS AND METHODS

We conducted a two-centre retrospective analysis of 905 patients (mean age 57.5 years, mean follow-up 78 months), who underwent RN (n = 610) or PN (n = 295) between July 1987 and June 2007. Demographics, preoperative and postoperative hyperlipidaemia were recorded. De novo hyperlipidaemia was defined as that ocurring ≥6 months after surgery in cases where laboratory values met National Cholesterol Education Program Adult Treatment Panel III definitions. The Kaplan-Meier method was used to assess freedom from de novo hyperlipidaemia. Multivariable analysis was conducted to determine the risk factors for de novo hyperlipidaemia.

RESULTS

There were no significant differences with respect to demographics, preoperative glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) (P = 0.123) and hyperlipidaemia (P = 0.144). Tumour size (cm) was significantly larger in the RN group vs the PN group (7.0 vs 3.7; P < 0.001). Significantly greater postoperative GFR <60 mL/min/1.73 m(2) was noted in the RN group (45.7 vs 18%, P < 0.001). Significantly, more de novo hyperlipidaemia developed in the RN group than in the PN group (23 vs 6.4%; P < 0.001). The mean time to development of hyperlipidaemia was longer for PN than for RN (54 vs 44 months; P = 0.03). Five-year freedom from de novo hyperlipidaemia probability was 76% for RN vs 96% for PN (P < 0.001). Multivariable analysis showed that RN (odds ratio [OR] 2.93; P = 0.0107), preoperative GFR <60 mL/min/1.73 m(2) (OR 1.98; P = 0.037) and postoperative GFR <60 mL/min/1.73 m(2) (OR 7.89; P < 0.001) were factors associated with hyperlipidaemia development.

CONCLUSION

Patients who underwent RN had a significantly higher incidence of and shorter time to development of de novo hyperlipidaemia. RN and pre- and postoperative eGFR <60 mL/min/1.73 m(2) were associated with development of hyperlipidaemia. Further follow-up and prospective investigation are necessary to confirm these findings.

Image based feasibility of renal sparing surgery for very low risk unilateral Wilms tumors: a report from the Children's Oncology Group

PURPOSE

Nephrectomy with lymph node sampling is the recommended treatment for children with unilateral Wilms tumor under the Children's Oncology Group protocols. Using radiological assessment, we determined the feasibility of performing partial nephrectomy in a select group of patients with very low risk unilateral Wilms tumor.

MATERIALS AND METHODS

We reviewed imaging studies of 60 patients with a mean age of less than 2 years with very low risk unilateral Wilms tumor (mean weight less than 550 gm) to assess the feasibility of partial nephrectomy. We evaluated percentage of salvageable parenchyma, tumor location and anatomical features preventing a nephron sparing approach.

RESULTS

A linear relationship exists between tumor weight and computerized tomography estimated tumor volume. Mean tumor weight in the study population was 315 gm. Partial nephrectomy was deemed feasible in only 5 of 60 patients (8%).

CONCLUSIONS

When considering a select population with very low risk unilateral Wilms tumor (lower volume tumor), only a small percentage of nonpretreated patients are candidates for nephron sparing surgery.

Oncology: the role of partial nephrectomy in Wilms tumor

Wilms tumor represents the most common pediatric renal malignancy and the fourth most common childhood cancer overall. Overall survival from Wilms tumor has increased to over 90 % secondary to multidisciplinary therapy and multi-institutional cooperative group trials. Recent therapeutic focus has shifted to reduction in treatment morbidity and renal preservation while maintaining the high survival rates. Partial nephrectomy is an integral component of the multimodal treatment protocols for Wilms tumor patients with bilateral disease, solitary kidney, or predisposing syndromes. Recent consideration has been given to utilization of nephron sparing surgery (NSS) in carefully selected patients with nonsyndromic unilateral Wilms tumor. While long-term, prospective data in this subgroup of patients is not yet available, case series demonstrate comparable oncologic outcomes after partial versus radical nephrectomy. The relative rarity of Wilms tumor, especially those amenable to upfront partial nephrectomy, presents a challenge to conducting controlled trials.

Does radical nephrectomy increase the risk of erectile dysfunction compared with partial nephrectomy? A cohort analysis

Study Type - Therapy (prospective cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). We hypothesized that partial nephrectomy (PN) would limit development of ED compared with radical nephrectomy (RN), primarily due to renal function preservation, and found that patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN; in addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. To our knowledge, this is the first study demonstrating an increased risk of ED after RN compared with PN.

OBJECTIVES

•  To evaluate prevalence and risk factors for development of erectile dysfunction (ED) in patients who underwent radical nephrectomy (RN) and partial nephrectomy (PN). •  ED is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). PN confers superior renal functional preservation compared with RN; however, the impact on ED is unclear.

METHODS

•  This was a retrospective study of 432 patients (264 RN/168 PN, mean age 58 years, mean follow-up 5.8 years) who underwent surgery for renal tumours between January 1998 and December 2007. •  The primary outcome was rate of de novo ED postoperatively. Secondary outcomes included development of CKD (estimated GFR < 60 mL/min/1.73 m(2) ) and response to phosphodiesterase-5 inhibitors. •  Multivariate analysis was performed to determine risk factors for de novo ED postoperatively.

RESULTS

•  RN and PN groups had similar demographics and comorbidities. •  Tumour size (cm) was larger for RN (RN 7.0 vs PN 3.7, P < 0.001) and more preoperative ED existed in PN vs RN (P= 0.042). No differences were observed for preoperative CKD, hyperlipidaemia and diabetes mellitus. •  Postoperatively, higher rates of de novo ED (29.5% vs 9.5%, P < 0.001) and CKD (33.0% vs 9.8%, P < 0.001) developed in RN vs PN cohorts, respectively. •  Of men with ED, 63% responded to phosphodiesterase inhibitors, without significant difference between the two groups (P= 0.896). •  Multivariate analysis demonstrated de novo ED to be associated with RN (odds ratio [OR] 3.56, P < 0.001), hypertension (OR 2.32, P= 0.014), preoperative (OR 8.77, P < 0.001) and postoperative (OR 2.64, P= 0.001) CKD, and postoperative diabetes mellitus (OR 2.93, P < 0.001).

CONCLUSIONS

•  Patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN. In addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. •  Further investigation on effects of surgically induced nephron loss on ED is requisite.