Outcome of kidney function after ischaemic and zero-ischaemic laparoscopic and open nephron-sparing surgery for renal cell cancer

Renal and major clinical outcomes and their determinants after nephrectomy in patients with pre-existing chronic kidney disease: A retrospective cohort study

The consequences of partial nephrectomy (PN) compared to radical nephrectomy (RN) are less documented in patients with pre-existing chronic kidney disease (CKD) or with solitary kidney (SK). We assessed renal outcomes, and their determinants, after PN or RN in a retrospective cohort of patients with moderate-to-severe CKD (RN-CKD and PN-CKD) or SK (PN-SK). All surgical procedures conducted between 2013 and 2018 in our institution in patients with pre-operative estimated glomerular filtration rate (eGFR)<60 mL/min/1.73m2 or with SK were included. The primary outcome was a composite criterion including CKD progression or major adverse cardio-vascular events (MACE) or death, assessed one year after surgery. Predictors of the primary outcome were determined using multivariate analyses. A total of 173 procedures were included (67 RN, and 106 PN including 27 SK patients). Patients undergoing RN were older, with larger tumors. Preoperative eGFR was not significantly different between the groups. One year after surgery, PN-CKD was associated with lower rate of the primary outcome compared to RN-CKD (43% vs 71% p = 0.007). In multivariate analysis, independent risk factors for the primary outcome were postoperative AKI (stage 1 to stage 3 ranging from OR = 8.68, 95% CI 3.23-23.33, to OR = 28.87, 95% CI 4.77-167.61), larger tumor size (OR = 1.21 per cm, 95% CI 1.02-1.45), while preoperative eGFR, age, sex, diabetes mellitus, and hypertension were not. Postoperative AKI after PN or RN was the major independent determinant of worse outcomes (CKD progression, MACE, or death) one year after surgery.

Low rate of severe-end-stage kidney disease after SABR for localised primary kidney cancer

BACKGROUND

Stereotactic ablative body radiotherapy (SABR) is an emerging treatment for patients with primary renal cell carcinoma (RCC). However, its impact on renal function is unclear. This study aimed to evaluate incidence and clinical factors predictive of severe to end-stage chronic kidney disease (CKD) after SABR for RCC.

METHODS AND MATERIALS

This was a Single institutional retrospective analysis of patients with diagnosed primary RCC receiving SABR between 2012-2020. Adult patients with no metastatic disease, baseline estimated glomerular filtration rate (eGFR) of ≥ 30 ml/min/1.73 m2, and at least one post-SABR eGFR at six months or later were included in this analysis. Patients with upper tract urothelial carcinoma were excluded. Primary outcome was freedom from severe to end-stage CKD, determined using the Kaplan-Meier estimator. The impact of baseline CKD, age, hypertension, diabetes, tumor size and fractionation schedule were assessed by Cox proportional hazard models.

RESULTS

Seventy-eight consecutive patients were included, with median age of 77.8 years (IQR 70-83), tumor size of 4.5 cm (IQR 3.9-5.8) and follow-up of 42.2 months (IQR 23-60). Baseline median eGFR was 58 mls/min; 55% (n = 43) of patients had baseline CKD stage 3 and the remainder stage 1-2. By last follow-up, 1/35 (2.8%) of baseline CKD 1-2, 7/27 (25.9%) CKD 3a and 11/16 (68.8%) CKD 3b had developed CKD stage 4-5. The estimated probability of freedom from CKD stage 4-5 at 1 and 5 years was 89.6% (CI 83.0-97.6) and 65% (CI 51.4-81.7) respectively. On univariable analysis, worse baseline CKD (p < 0.0001) and multi-fraction SABR (p = 0.005) were predictive for development of stage 4-5 CKD though only the former remained significant in multivariable model.

CONCLUSION

In this elderly cohort with pre-existing renal dysfunction, SABR achieved satisfactory nephron sparing with acceptable rates of severe to end-stage CKD. It can be an attractive option in patients who are medically inoperable.

Surgery in Bilateral Wilms Tumor-A Single-Center Experience

The treatment of bilateral Wilms tumors (BWT) involves curing the cancer, preserving long-term renal function, and maintaining a good quality of life. Established methods for achieving these goals include preoperative chemotherapy and nephron-sparing surgery (NSS). This study aimed to evaluate the experience of a single institution in treating patients with BWT. We analyzed cases of BWT treated at the Pediatric Oncology Institute-GRAACC-Federal University of São Paulo over a period of 35 years. Bleeding control was performed with manual compression of the renal parenchyma. Thirty-three patients were included in the study. Thirty cases were synchronous tumors. The mean age at diagnosis was 30.4 months (±22 m) and 66.7% were girls. The median follow-up period was 83 months. Neoadjuvant chemotherapy was the primary approach in most patients (87.9%), with a simultaneous upfront surgical approach performed in 84.8%. Most patients underwent bilateral NSS (70.4%). There were no early complications in this series, but 39.4% had clinical complications. The five-year survival rate was 76%. Therefore, it is clear that the surgical approach to BWT plays a crucial role in achieving good outcomes. However, it is difficult to standardize surgical techniques and technology may have the potential to enhance safety.

Prediction of surgical decision and postoperative renal function using RENAL nephrometry score for localized renal masses: A prospective study

Purpose

The purpose of the study is to assess the value of RENAL nephrometry score (RNS) in predicting surgical decisions, complications, and decreases in kidney function in patients with localized renal tumors.

Methods

Cases with solitary, solid, and enhancing renal masses were included, scheduled for nephron-sparing surgery (NSS), and assessed using routine laboratory and radiological data necessary for calculating the RENAL score. The primary endpoint was conversion to radical nephrectomy (RN), while the secondary endpoint was the prediction of a drop in renal function assessed by postoperative estimated glomerular filtration rate (eGFR) at the last follow-up visit compared with the preoperative values. The association between the scoring system and perioperative outcomes was evaluated.

Results

In all, 84 cases were included, NSS was accomplished in 67 cases while conversion to RN was mandatory in 17 patients, median (interquartile range) RENAL score was 6.2 (4-10) for NSS and 9.7 (6-12) for RN (P < 0.001). Higher grades of complications were observed in the high-complexity subgroup. eGFR was 79.8 that dropped to 75.6 ml/min/1.73 m2 in the late value in patients who underwent NSS, while it was 82.9 that dropped to 58.3 ml/min/1.73 m2 in the late value in patients who converted into RN (P < 0.001). The percentage of drop in eGFR was significantly higher in the moderate and high-risk groups, which was positively correlated with the warm ischemia time. Regression analysis revealed that the continuous RENAL score was a more significant predictor of conversion to RN than tumor size alone. In the 67 NNS cases, the percentage decrease in eGFR was predicted using the continuous RENAL score.

Conclusion

The RNS is a significant predictor of conversion to RN and can predict the percentage decrease in eGFR after NSS. Further investigations and follow-ups are necessary.

Second malignant tumors and non-tumor causes of death for patients with localized and regional kidney cancer after diagnosis

BACKGROUND

To evaluate the second malignant tumors (SMTs) and non-tumor causes of death among patients diagnosed with localized and regional kidney cancer.

METHODS

Patients diagnosed with kidney cancer between 2000 and 2017 in the Surveillance, Epidemiology, and End Results (SEER) program database were identified. All causes of death for patients during the follow-up and standardized mortality ratio (SMR) were analyzed.

RESULT

113,734 patients with localized kidney cancer with 30,390 cases of death were analyzed. 60.4% of the death cases were due to non-tumor caused and 23.6% were second malignant tumors (SMTs). Main SMTs included cancers of lung and bronchus [n = 1,283, SMR: 1.00 (0.95-1.06)] and pancreas [n = 393, SMR: 1.27 (1.15-1.41)]. Causes of death for non-tumor mainly included heart diseases [n = 6,161, SMR: 1.25 (1.21-1.28)] and chronic obstructive pulmonary disease (COPD) [n = 1,185, SMR: 0.99 (0.94-1.05)]. 14,437 of 29,602 patients with regional kidney cancer died. 14.6% of all deaths were due to SMTs and 23.6% due to non-tumor causes. Main SMTs contained bladder cancer [n = 371, SMR: 10.90 (9.81-12.06)] and lung and bronchus cancer [n = 346, SMR: 1.21 (1.08-1.34)]. The main non-tumor death was heart disease [n = 1,424, SMR: 1.26 (1.2-1.33)]. When stratified by pathological types, patients with clear cell renal cell carcinoma (RCC) did not have increased mortality risks of bladder cancer and lung cancer but patients with non-clear cell RCC did.

CONCLUSION

SMTs and non-tumor diseases including lung and bronchus cancer, bladder cancer, pancreas cancer, diseases of heart, COPD, and cerebrovascular diseases are the leading causes of death besides kidney cancer and should be paid more attention during patients' survival period.

Limited non-linear impact of warm ischemia time on renal functional decline after partial nephrectomy: a propensity score-matched study

OBJECTIVE

To quantificationally illustrate the impact of ischemia time (IT) on renal function decline after partial nephrectomy (PN), especially for patients with compromised baseline renal function (estimated glomerular filtration rate [eGFR] < 90 mL/min/1.73 m²).

METHODS

Patients undergoing PN during 2014-2021 from a prospectively maintained database were reviewed. Propensity score matching (PSM) was employed to balance the possible covariates between patients with or without baseline compromised renal function. Specifically, the relationship of IT with postoperative renal function was illustrated. Two machine learning methods (logistic least absolute shrinkage and selection operator [LASSO] logistic regression and random forest) were applied to quantify the relative impact of each covariables.

RESULTS

The average drop percent of eGFR was -10.9% (- 12.2%, - 9.0%). Multivariable Cox proportional regression and linear regression analyses identified five risk factors for renal function decline, namely RENAL Nephrometry Score (RNS), age, baseline eGFR, diabetes and IT (all p < 0.05). Specifically, the relationship of IT with postoperative functional decline emerged as non-linear, with an increase from 10-30 min and a plateau afterwards among patients with normal function (eGFR ≥ 90 mL/min/1.73 m²), whereas with an increase from 10 to 20 min and a plateau afterwards among patients with compromised function (eGFR < 90 mL/min/1.73 m²). Furthermore, the coefficient's path and random forest analysis revealed that the top two most important features were RNS and age.

CONCLUSION

IT exhibits the secondarily non-linear relationship with postoperative renal function decline. Patients with compromised baseline renal function are less tolerant to ischemia damage. The use of a single cut-off interval of IT in the setting of PN is flawed.

Outcomes of open partial nephrectomy for renal cell carcinoma in the minimally invasive approach era

Background:

We investigated the characteristics and outcomes of patients who underwent open partial nephrectomy (OPN) in the minimally invasive approach era.

Materials and methods:

We retrospectively reviewed 52 patients (55 cases) who underwent OPN from May 2009 to March 2016. We assessed perioperative change in estimated glomerular filtration rate (eGFR), complications, and oncological outcomes. Tumor complexity was evaluated using the R.E.N.A.L nephrometry score (NS) and the modified NS.

Results:

Fifteen cases (27%) had imperative indications and 40 (73%) had elective indications. The elective cases were more likely to have adverse tumor complexity based on NS. The perioperative complication rate defined as a Clavien-Dindo grade ≥IIIa was 11%. The rate of postoperative decline in eGFR at 1 month, 1 year, and 2 years was 22%, 20%, and 21%, respectively. Multivariate analysis revealed that male gender (odds ratio [OR] 11.8, p = 0.03), NS ≥9 (OR 13.9, p = 0.02), modified NS ≥11 (OR 13.5, p = 0.01), and cold ischemic time ≥40 minutes (OR 7.9, p = 0.04) were significantly associated with worsening eGFR at 1 year after surgery. During a median follow-up period of 52 months, the 5-year overall survival and recurrence-free survival rates were 93% and 84%, respectively.

Conclusions:

OPN is acceptable with regard to oncological outcomes and complications in the minimally invasive surgery era. We propose that OPN should be the preferred approach in cases in which it is technically difficult to preserve maximum renal function via a minimally invasive approach.

A Report of 61 Cases of Retroperitoneal Laparoscopic Nephron-Sparing Surgery and Factors Affecting Postoperative Renal Function

Objective

To explore the situation of 61 patients with renal tumors who underwent retroperitoneal laparoscopic nephron-sparing surgery (RLNSS) and the factors affecting postoperative renal function.

Methods

A total of 61 patients with renal tumors who underwent RLNSS in our hospital from January 2018 to January 2021 were included in this study. All patients were treated with RLNSS. The clinical data of patients were recorded. Before operation and 3 months after operation, the change value of glomerular filtration rate (ΔGFR) was measured by the Gates method. Multivariate linear regression was used to analyze the related factors affecting postoperative renal function.

Results

All 61 patients successfully completed the operation. The mean operative time was 60–150 min‚ average (98.75 ± 14.38) min. The estimated intraoperative blood loss was 20–310 ml‚ average (107.93 ± 68.55) ml. Intraoperative warm ischemia time (WIT) was 0–39 min, with an average of (21.16 ± 6.47) min. All patients' pathological margins were negative after operation. In all patients, there were 5 postoperative complications, including 2 cases of renal wound bleeding (3.28%), 1 case of hematuria (1.64%), 1 case of urinary fistula (1.64%), and 1 case of subcutaneous emphysema (1.64%). There were significant differences in tumor diameter, preoperative GFR, operation time and WIT (P < 0.05). Multivariate analysis showed that tumor diameter, preoperative GFR, and WIT were all factors affecting the postoperative renal function of patients with RLNSS (P < 0.05).

Conclusion

RLNSS has a good curative effect on patients with renal tumor, and tumor diameter, preoperative GFR, and WIT were all factors affecting the postoperative renal function of patients with RLNSS.

Robotic-Assisted Partial Nephrectomy: Techniques to Improve Clinical Outcomes

PURPOSE OF REVIEW

To summarize current options available for robot-assisted partial nephrectomy RECENT FINDINGS: Partial nephrectomy (PN) is a standard treatment option for management of cT1 renal masses. It may be carried out by multiple approaches. Robot-assisted (RA) PN is one such option. The goal of treatment is both correct oncological (negative surgical margins) and functional (preservation of sufficient amount of renal parenchyma of the operated kidney) outcome. Appropriate outcomes depend on multiple factors. There are many, but among others tumor characteristics (size, location, i.e., tumor complexity), patient baseline renal function, patient comorbidities, and performance status etc. Based on all these, the surgeon adapts the intervention for each mass/patient by preoperative planning, absence/use/duration of warm or cold ischemia, perioperative imaging, resection technique adapted to tumor location and depth of invasion, use of hemostatics, type and degree of renal parenchymal closure and others details. Nephroprotective agents have not shown efficacy so far. It should not be forgotten that surgeon's experience plays a key role in the achievement of good results. Although multiple factors have a role in the RA partial nephrectomy, surgeon experience and adaptation of technique of intervention have the crucial role in the achievement of both functional and oncological results.

Comparison of Perioperative Outcomes Between Laparoscopic and Open Partial Nephrectomy for Different Complexity Renal Cell Carcinoma Based on the R.E.N.A.L. Nephrometry Score

Purpose

This study aimed to compare perioperative outcomes of open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) from a retrospective single-center dataset.

Patients and Methods

A retrospective single-center analysis of 210 patients who underwent open (n=91) or laparoscopic (n =119) partial nephrectomy for RCC was conducted between 2012 and 2015. All patients were grouped into low complexity, moderate complexity, and high complexity according to the R.E.N.A.L. Nephrometry Score, respectively. The rates of intraoperative and postoperative complications estimated blood loss, warm ischemia time, operative time, conversion of laparoscopic procedure to open surgery, and postoperative length of stay were assessed for both procedures.

Results

In low complexity group (n=93), patients undergoing LPN (n=52) under ischemia conditions had significantly longer renal artery clamp time (p < 0.001) and operative time (p = 0.001) compared with OPN (n=41). However, patients undergoing LPN had a significantly less postoperative length of stay (p=0.005) and estimated blood loss (p < 0.001) compared with OPN. There was no statistically significant difference in the rates of complications between LPN and OPN. In the moderate complexity group (n=114), 67 and 47 patients underwent LPN and OPN, respectively. LPN had notably longer warm ischemia time (p < 0.001) and operative time (p < 0.001) compared with OPN. There were no statistically significant differences in the rates of complications, estimated blood loss, and postoperative length of stay between LPN and OPN. In the high complexity group (n=3), all patients underwent OPN.

Conclusion

OPN and LPN procedures performed in patients with low and moderate complexity tumors based on the RENAL Nephrometry score offer acceptable and comparable results. When applied to low complexity tumors, our data suggest that laparoscopic NSS is an effective, minimally invasive therapeutic approach with the advantages of less blood loss, earlier hospital discharge, and more rapid convalescence.

A retrospective study of open and endoscopic nephron sparing surgery in the treatment of complex renal tumors

Objective:

To investigate clinical outcomes of open and retroperitoneal laparoscopic nephron-sparing surgery in the treatment of complex renal tumours.

Methods:

A retrospective case study was conducted. Patients with complex renal tumours admitted to our hospital between January 2018 and September 2019 were enrolled; the included patients (n=40) were divided into the observation group (open partial nephrectomy, n=20) and control group (laparoscopic partial nephrectomy, n=20) according to operation modes. The operation time, renal warm ischaemia time, intraoperative blood loss, renal pedicle blocking time, intestinal function recovery time, postoperative hospital stay, and postoperative complications were recorded.

Results:

Significant differences were noted regarding renal warm ischaemia time, renal pedicle blocking time, intraoperative blood loss, operation time, and postoperative hospital stay between the observation and control groups (P<0.05); however, no significant difference was observed in intestinal function recovery time and postoperative drainage days (P>0.05).

Conclusion:

Open surgery remains the recommended surgical method for the treatment of few complex tumours in the renal hilus region and has gradually become the renal surgery of choice at present, although laparoscopic surgery has evolved tremendously.

Versatility and clinical effectiveness of a synthetic sealing hemostatic patch as alternative to parenchyma suturing in laparoscopic partial nephrectomy

BACKGROUND

Improvements in laparoscopic partial nephrectomy (LPN) in order to minimize perioperative warm ischemia time (WIT), complications, and consequently patient outcome are desirable. Veriset™ is a ready-to-use hemostatic patch of absorbable oxidized cellulose and hydrogel components that has earlier been implemented in vascular and hepatic surgery. We report our experience using this device in LPN.

METHODS

Patients with a solitary malignant renal mass suspicious for renal cancer underwent LPN with either the use of Veriset™ hemostatic patch (n = 40) or conventional suture technique (n = 40). Patient characteristics, operation time and WIT, postoperative course and complications were recorded retrospectively. Tumor complexity was calculated according to the R.E.N.A.L. score. Outcome was determined according to the "trifecta" criteria (negative surgical margin, WIT < 25 min, no complications within 30 days).

RESULTS

No significant differences with regard to clinical parameters and median R.E.N.A.L. score (6) were observed between both groups. Operation time (mean 127.1 min vs. 162. 8 min; p = 0.001) and WIT were both lower in the Veriset™ group (14.6 min vs. 20.6 min; p = 0.01). No differences in surgical margins (p = 0.602) and overall complication rates at 30 (p = 0.599) and 90 days (p = 0.611) postoperatively were noticed. The surgical outcome according to "trifecta" was achieved in 65% of patients using Veriset™ and in 57.5% of patients by suture closure, respectively.

CONCLUSION

The hemostatic Veriset™ patch can successfully be implemented in LPN. Handling and application appear favorable, thereby reducing operation time and WIT. The present results suggest that the device may represent an alternative to parenchyma suturing in LPN.