Utilization Rates of Pancreatectomy, Radical Prostatectomy, and Nephrectomy in New York, Ontario, and New South Wales, 2011 to 2018

Importance

Few studies have compared surgical utilization between countries or how rates may differ according to patients' socioeconomic status.

Objective

To compare population-level utilization of 3 common nonemergent surgical procedures in New York State (US), Ontario (Canada), and New South Wales (Australia) and how utilization differs for residents of lower- and higher-income neighborhoods.

Design, Setting, and Participants

This cohort study included all adults aged 18 years and older who were hospitalized for pancreatectomy, radical prostatectomy, or nephrectomy between 2011 and 2016 in New York, between 2011 and 2018 in Ontario, and between 2013 and 2018 in New South Wales. Each patient's address of residence was linked to 2016 census data to ascertain neighborhood income. Data were analyzed from August 2019 to November 2020.

Main Outcomes and Measures

Primary outcomes were (1) each jurisdiction's per capita age- and sex-standardized utilization rates (procedures per 100 000 residents per year) for each surgery and (2) utilization rates among residents of lower- and higher-income neighborhoods.

Results

This study included 115 428 surgical patients (25 780 [22.3%] women); 5717, 21 752, and 24 617 patients in New York were hospitalized for pancreatectomy, radical prostatectomy, and nephrectomy, respectively; 4929, 19 125, and 16 916 patients in Ontario, respectively; and 2069, 13 499, and 6804 patients in New South Wales, respectively. Patients in New South Wales were older for all procedures (eg, radical prostatectomy, mean [SD] age in New South Wales, 64.8 [7.3] years; in New York, 62.7 [8.4] years; in Ontario, 62.8 [6.7] years; P < .001); patients in New York were more likely than those in other locations to be women for pancreatectomy (New York: 2926 [51.2%]; Ontario: 2372 [48.1%]; New South Wales, 1003 [48.5%]; P = .004) and nephrectomy (New York: 10 645 [43.2%]; Ontario: 6529 [38.6%]; 2605 [38.3%]; P < .001). With the exception of nephrectomy in Ontario, there was a higher annual utilization rate for all procedures in all jurisdictions among patients residing in affluent neighborhoods (quintile 5) compared with poorer neighborhoods (quintile 1). This difference was largest in New South Wales for pancreatectomy (4.65 additional procedures per 100 000 residents [SE, 0.28]; P < .001) and radical prostatectomy (73.46 additional procedures per 100 000 residents [SE, 1.20]; P < .001); largest in New York for nephrectomy (8.43 additional procedures per 100 000 residents [SE, 0.85]; P < .001) and smallest in New York for radical prostatectomy (19.70 additional procedures per 100 000 residents [SE, 2.63]; P < .001); and smallest in Ontario for pancreatectomy (1.15 additional procedures per 100 000 residents [SE, 0.28]; P < .001) and nephrectomy (-1.10 additional procedures per 100 000 residents [SE, 0.52]; P < .001). New York had the highest utilization of nephrectomy (28.93 procedures per 100 000 residents per year [SE, 0.18]) and New South Wales for had the highest utilization of pancreatectomy and radical prostatectomy (6.94 procedures per 100 000 residents per year [SE, 0.15] and 94.37 procedures per 100 000 residents per year [SE, 0.81], respectively; all P < .001). Utilization was lowest in Ontario for all procedures (pancreatectomy, 6.18 procedures per 100 000 residents per year [SE, 0.09]; radical prostatectomy, 49.24 procedures per 100 000 residents per year [SE, 0.36]; nephrectomy, 21.40 procedures per 100 000 residents per year [SE, 0.16]; all P < .001).

Conclusions and Relevance

In this study, New York and New South Wales had higher per capita surgical utilization and larger neighborhood income-utilization gradients than Ontario. These findings suggest that income-based disparities are larger in the United States and Australia and smaller in Canada and highlight trade-offs inherent in the health care systems of different countries.

Hydronephrosis in patients with cervical cancer is an indicator of poor outcome: A nationwide population-based retrospective cohort study

Cervical cancer is a common malignancy in women. The presence of hydronephrosis in patients with cervical cancer can be a challenging clinical problem. The appropriate management of these patients and the prediction of their outcomes are concerns among gynecologists, urologists, medical oncologists, radiation oncologists, and nephrologists. We enrolled a total of 2225 patients with cervical cancer over a 12-year period from the nationwide database of Taiwan's National Health Insurance Bureau. Among them, 445 patients had concomitant hydronephrosis. The remaining 1780 patients without hydronephrosis were randomly enrolled as a control group for the analysis of associated factors. The results indicated that the proportions of patients with hypertension, chronic kidney disease, and diabetes were significantly higher in the hydronephrosis group. The hydronephrosis group showed a higher all-cause mortality than the non-hydronephrosis group (adjusted hazard ratio 3.05, 95% confidence interval 2.24-4.15, P < .001). The rates of nephrectomy and stone disease were also significantly higher in the hydronephrosis group. A higher percentage of other cancers was also observed in the hydronephrosis group than in the non-hydronephrosis group (12.36% vs 8.99%, respectively). This study shows that cervical cancer with hydronephrosis may have a higher morbidity and mortality than cervical cancer without hydronephrosis. Other factors such as human papilloma virus vaccination, smoking, and cancer staging need to be further studied.

Tumor volume: a new prognostic factor of oncological outcome of localized clear cell renal cell carcinoma

BACKGROUND

Clear cell renal cell carcinoma (ccRCC) is one of the most frequent malignancies; however, the present prognostic factors was deficient. This study aims to explore whether there is a relationship between tumor volume (TV) and oncological outcomes for localized ccRCC.

METHODS

Seven hundred forty-nine localized ccRCC patients underwent surgery in our hospital. TV was outlined and calculated using a three-dimensional conformal radiotherapy planning system. We used receiver operating characteristic (ROC) curves to identified optimal cut-off value. Univariable and multivariable Cox regression models were performed to explore the association between TV and oncological outcomes. Kaplan-Meier method and log-rank test were used to estimate survival probabilities and determine the significance, respectively. Time-dependent ROC curve was utilized to assess the prognostic effect.

RESULTS

Log rank test showed that higher Fuhrman grade, advanced pT classification and higher TV were associated with shortened OS, cancer-specific survival (CSS), freedom from metastasis (FFM) and freedom from local recurrence (FFLR). multivariable analysis showed higher Fuhrman grade and higher TV were predictors of adverse OS and CSS. The AUC of TV for FFLR was 0.822. The AUC of TV (0.864) for FFM was higher than that of pT classification (0.818) and Fuhrman grade (0.803). For OS and CSS, the AUC of TV was higher than that of Fuhrman grade (0.832 vs. 0.799; 0.829 vs 0.790).

CONCLUSIONS

High TV was an independent predictor of poor CSS, OS, FFLR and FFM of localized ccRCC. Compared with pT classification and Fuhrman grade, TV could be a new and better prognostic factor of oncological outcome of localized ccRCC, which might contribute to tailored follow-up or management strategies.

Does routine repeat imaging for blunt high-grade renal trauma lead to unnecessary interventions?

BACKGROUND

Most high-grade renal injuries with urinary extravasation (UE) may be managed conservatively without intervention. For such patients, the American Urological Association Urotrauma guidelines recommend repeat imaging within 48 to 72 hours of injury. We sought to examine whether routine, proactive follow-up renal imaging was associated with need for urologic intervention or risk of complications.

METHODS

Patients treated to an urban level 1 trauma center for a five-state region, between 2005 and 2017 were identified by International Classification of Diseases, Ninth Revision and Tenth Revision, codes from a prospectively collected institutional trauma registry. Individual patient charts and imaging were reviewed to identify all patients with American Association for the Surgery of Trauma grade IV renal injuries. Those with UE were included, and patients with penetrating trauma, immediate urologic surgery, or in-hospital mortality were excluded.

RESULTS

Of 342 patients with grade IV injuries, 108 (32%) met the inclusion criteria. Urologic intervention was performed in 23% (25 of 108 patients) including endoscopic procedure (24 of 108 patients) and nephrectomy (1 of 108 patients). Repeat imaging was performed within 48 to 72 hours after initial imaging in 65% (70 to 108 patients). Patients who underwent routine reimaging had a higher rate of undergoing subsequent urologic procedure (31.4% vs. 7.1%, p = 0.008). For patients with reimaging who underwent a procedure, 18% (4 of 22 patients) were symptomatic, while all nonroutinely reimaged patients who underwent a procedure were symptomatic (3 of 3 patients). Patients who received routine repeat imaging had a higher mean number of abdominal computed tomography scans during their admission (2.5 vs. 1.7, p < 0.001), while the complication rate was similar between groups.

CONCLUSIONS

Patients with grade IV renal lacerations with UE from blunt trauma who received routine repeat imaging were more likely to undergo an operation in the absence of symptoms and received more radiation during their hospital stay. Forgoing repeat imaging was not associated with an increase in urological complications. These data suggest that, in the absence of signs/symptoms, repeat imaging may be avoidable.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Single-port Robotic Surgery Allows Same-day Discharge in Majority of Cases

OBJECTIVE

To assess the influence of single-port (SP) robotic surgery on length of stay (LOS) in our initial experience using the da Vinci SP robot as compared with traditional, multiport procedures.

METHODS

We evaluated our single surgeon (RA) prospective database for the initial 100 SP procedures performed between January 2019 and January 2020. Patient LOS was compared with standard multiport robotic surgery patients since we began routinely offering same-day discharge (SDD) in September 2016.

RESULTS

Among the initial 100 SP robotic surgeries, there were 59 prostatectomies, 18 partial nephrectomies, 12 pyeloplasties, 4 nephrectomies, 4 adrenalectomies, 2 partial cystectomies, and 1 nephroureterectomy. The rate of SDD in SP procedures was higher compared to our historical SDD for multiport robotic surgeries despite uniformly offering SDD to all patients in both groups (88% vs 51%, P < .0001). Among prostatectomies, 88% of SP patients were discharged the same day versus 55% (P < .001). Among partial nephrectomies, 83% of SP patients went home the same day versus 17% (P < .001) as well as 83% of pyeloplasty patients versus 52% (P = .064). For SP adrenalectomy, nephrectomy, partial cystectomy, and nephroureterectomy, all were discharged the same day.

CONCLUSION

Our initial experience with SP robotic surgery suggests earlier discharge is possible with the large majority (88%) so far opting to go home the same day as surgery. Further experience will be necessary to allow analysis of pain scores and analgesic usage as potential causative factors.

Preoperative assessment system for hand-assisted laparoscopic donor nephrectomy by discriminant analysis

We developed a preoperative assessment system to predict surgical workload in hand-assisted laparoscopic donor nephrectomy (HALDNx) using the normal-based linear discriminant rule (NLDR). A total of 128 cases of left HALDNx performed by a single operator were used as training data. Surgical workload was measured by operative time. The optimized model had 9 explanatory variables: age, total protein, total cholesterol, number of renal arteries (numberRA), 4 variables of perinephric fat (PNF), and thickness of subcutaneous fat. This model was validated using cross-validation and the .632 estimator to estimate discrimination rates with future test data. PNF and numberRA were the predominant factors affecting workload followed by the computed tomography value of PNF, body weight, and male sex. The estimated accuracy of the prediction system was 94.6%. The complication rate was 9.38% and did not correlate with surgical workload. We also made our program available online for constructing assessment functions from other cohort data. In conclusion, the surgical workload of HALDNx could be predicted with PNF and numberRA as the dominant risk factors.

Current role of open surgery in adrenal tumors

AIM

The aim of this retrospective evaluation is to assess the current role of open adrenalectomy, in particular in cases of adrenocortical carcinoma (ACC).

MATERIALS AND METHODS

From January 2009 to May 2019, 26 open out of 233 adrenalectomies were performed in our Academic Department. Open adrenalectomy was performed by the anterior approach. A midline abdominal incision or a subcostal surgical incision was used to reach the peritoneal cavity. The resection was defined R0 if the margins of the sample were negative for malignancy.

RESULTS

Open adrenalectomy was performed in 26 patients: 10 men and 16 women with a mean age of 61±25.3 years and a mean BMI of 28.4±2.9. The right adrenal gland was removed in 15 cases Romaand the left in 11 cases.We reported 18 diagnosis of malignant pathology. The other diagnosis concerned 5 cases of pheochromocytoma, 1 case of Cushing's disease and 2 cases of hyperaldosteronism. Mean tumor size was 7.7±5.5. Mean operative time was 160 min (range=110-205 minutes). Mean postoperative stay was 7±2 days. Only 3 (10%) patient showed postoperative grade II complications, according to Clavien-Dindo classification. Midline abdominal incision was used in 18 patients, subcostalsurgical incision in 5 patients and bilateral subcostal surgical incision in 3 patients. 3 right nephrectomy was necessary to remove the entire tumor mass. An en bloc R0 tumor resection was accomplished in all cases.There was no intra and perioperative mortality. All patients recovered well from surgery. The mean follow-up period was 15 (range=6-48) months.

CONCLUSION

In conclusion, our retrospective study points out the role of open adrenalectomy as the treatment of choice in selected cases with known or suspected malignant adrenal tumors and with size greater than 12 cm.

Renal surgery for the older population: time for a paradigm shift? Data from the RESURGE project

AIM

To provide a comprehensive analysis of the outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) for renal cell carcinoma (RCC) in older patients.

METHODS

The RESURGE project is a multi-institutional dataset including 24 institutions worldwide collecting data of patients older than 75 years old who underwent RN or PN.

RESULTS

Among three already published studies, RN patients were older (p < 0.001), and presented a higher RENAL score (p < 0.001). PN showed shorter operative time (p = 0.020), as well as lower eGFR postoperative decline (p < 0.001). No statistically significant difference was found in terms of major complications between PN and RN. PN was shown to be protective factor with respect to de novo chronic kidney disease (CKD) (p < 0.001). RN was related to a higher rate of recurrence (p < 0.001), whereas PN demonstrated lower risk of cancer-specific mortality (CSM) (p = 0.05).

CONCLUSIONS

Data from the RESURGE project suggest that kidney cancer surgery could be feasible and safe in well-selected older patients. When surgery is indicated, PN should be preferred to RN as it offers better functional preservation. Otherwise, less invasive or non-interventional management options should be considered.

Prediction of significant estimated glomerular filtration rate decline after renal unit removal to aid in the clinical choice between radical and partial nephrectomy in patients with a renal mass and normal renal function

OBJECTIVES

To develop a clinically applicable predictive model to quantitate the risk of estimated glomerular filtration rate (eGFR) decline to ≤45 mL/min/1.73 m2 after radical nephrectomy (RN) to better inform decisions between RN and partial nephrectomy (PN).

PATIENTS AND METHODS

Our prospectively maintained kidney cancer registry was reviewed for patients with a preoperative eGFR >60 mL/min/1.73 m2 who underwent RN for a localized renal mass. New baseline renal function was indexed. We used multivariable logistic regression to develop a predictive nomogram and evaluated it using receiver-operating characteristic (ROC) analysis. Decision-curve analysis was used to assess the net clinical benefit.

RESULTS

A total of 668 patients met the inclusion criteria, of whom 183 (27%) experienced a decline in eGFR to ≤45 mL/min/1.73 m2 . On multivariable analysis, increasing age (P = 0.001), female gender (P < 0.001), and increasing preoperative creatinine level (P < 0.001) were associated with functional decline. We constructed a predictive nomogram that included these variables in addition to comorbidities with a known association with kidney disease, but found that a simplified model excluding comorbidities was equally robust (cross-validated area under the ROC curve was 0.78). Decision-curve analysis showed the net clinical benefit at probabilities >~11%.

CONCLUSIONS

The decision to perform RN vs PN is multifaceted. We have provided a simple quantitative tool to help identify patients at risk of a postoperative eGFR of ≤45 mL/min/1.73 m2 , who may be stronger candidates for nephron preservation.

Novel Predictive Models of Early Death Less Than 1 Year in Patients With Metastatic Renal Cell Carcinoma After Treatment With First-line Tyrosine Kinase Inhibitors

BACKGROUND

We aimed to develop a modified International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) model that can predict early death less than 1 year in patients with metastatic renal cell carcinoma (mRCC) after receiving first-line tyrosine kinase inhibitors (TKIs).

PATIENTS AND METHODS

We retrospectively reviewed records of patients with mRCC treated with first-line TKIs at our institution between 2007 and 2012. The primary endpoint was the rate of early death within 1 year after first-line TKI administration. We determined statistically significant factors predicting early death by performing multiple logistic regression. The modified IMDC model 1 was developed using new variables in addition to the risk criteria of the IMDC model, and model 2 was developed using new variables irrespective of the risk classification of IMDC model.

RESULTS

Early mortality within 1 year of first-line TKI treatment was 19.7% (n = 98) in 462 patients. Although the C-index of the IMDC model for early death was 0.655, the C-index of model 1, which includes 5 variables (previous nephrectomy, body mass index, multiple metastases, previous metastasectomy, and serum albumin level) in addition to the Heng criteria, was 0.823. The C-index of model 2, which includes 7 variables (hemoglobin, neutrophil level, and the 5 variables of model 1) was 0.822. Of note, there was no significant difference in net reclassification index between the 2 models.

CONCLUSION

This is the first study suggesting novel prediction models for early death less than 1 year in patients with mRCC treated with first-line TKI.

Urinary Stone Disease and Preventable Nephrectomies

BACKGROUND

Urinary stone disease has high prevalence in our belt. The end stage complication of this disease turns out to be a non-functioning kidney, which in fact could be prevented by means of appropriate treatment and follow up.

METHODS

This is retrospective study of the nephrectomy cases of last 8 years retrieved from the hospital database. Variables like age, sex, indications for nephrectomy, modalities of nephrectomy and morbidities among the primary and recurrent disease were taken into consideration. Analysis were done using Microsoft Excel 2016.

RESULTS

Five hundred and twenty-nine nephrectomies were performed in last 8 years at our hospital. Female were more prone for nephrectomies. Age at third and fourth decade were most to be affected. Ninety percentage of nephrectomies were done for benign causes, 65% for the stone disease. The recurrent renal stone disease without any past surgical interventions were more prone to undergo nephrectomies. The conventional open technique of nephrectomy has largely been replaced by laparoscopic means in recent years.

CONCLUSIONS

The main contributor for nephrectomy in our context is urinary stone disease, which is considered to be the preventable factor Keywords: Nephrectomy; renal stone; urinary stone disease.

Solitary kidney and risk of chronic kidney disease

The renal outcome of solitary kidney remains controversial. We examined the longitudinal association of congenital or acquired solitary kidney with the development of chronic kidney disease (CKD). A cohort study was performed involving 271,171 Korean men and women free of CKD at baseline who underwent a health screening program and who were followed annually or biennially for an average of 5.4 years. Solitary kidney was determined based on ultrasonographic findings. CKD was defined as an estimated glomerular filtration rate of < 60 ml/min/1.73 m² and/or the presence of proteinuria in two or more consecutive visits. During 1,472,519.6 person-years of follow-up, 2989 participants developed CKD (incidence rate: 2.0 per 1000 person-years). After adjustment for potential confounders, the aHR (95% CIs) for incident CKD comparing solitary kidney to the control was 3.26 (1.63-6.54). In analyses of cause-specific solitary kidney, aHR (95% CIs) for CKD comparing unilateral nephrectomy and congenital solitary kidney to the control were 6.18 (2.31-16.49) and 2.22 (0.83-5.92), respectively. The association between solitary kidney and CKD was stronger in men. Having a solitary kidney was independently associated with an increased risk of CKD development. Therefore, preventive strategies for reducing the risk of CKD are required in individuals with a solitary kidney.

Prognostic implications of renal vein involvement in T3a renal cancer

INTRODUCTION

The TNM staging system is used globally as the standard for interpreting the extent of cancer. Currently, T3a renal cell carcinoma is classified as tumor extending into the perinephric fat or renal vein. Prognostic outcomes may vary among renal cell carcinomas with renal vein involvement (RVI) versus those with perinephric fat involvement (PFI).

MATERIALS AND METHODS

We reviewed the medical records of all patients who underwent radical or partial nephrectomy at our institution by a single group of urologists between 2000 and 2014. After identifying those patients with T3a renal cell carcinoma, we further analyzed their prognostic features. Overall and disease-free survival using Kaplan-Meier analysis with log rank comparison was performed among patients with renal vein involvement and PFI. Gender, smoking status, age at diagnosis, body mass index, tumor grade, tumor size, and tumor histology were also analyzed.

RESULTS

Of 139 patients with T3a renal cell carcinoma, 42 patients were found to have RVI, leaving 97 patients with PFI. Mean follow up was 52.1 months (0.3-183.4) versus 28.8 months (0.3-98.0) for patients with PFI and RVI, respectively. Overall survival (p < 0.048) and disease-free survival (p < 0.049) were significantly lower for patients with RVI.

CONCLUSION

In our study, patients with T3a renal cell carcinoma that have RVI as opposed to PFI have lower overall and disease-free survival. These findings suggest that patient with T3a renal cell carcinoma with RVI should be monitored more closely than their counterparts with only PFI.

Operative outcomes of robotic partial nephrectomy. A report of the first 101 cases from a single center in Saudi Arabia

OBJECTIVES

To report robotic partial nephrectomy (RPN) outcomes from a single tertiary hospital in Saudi Arabia. Methods: We retrospectively reviewed consecutive cases of patients undergoing RPN at King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of  Saudi Arabia, between January 2008 and January 2018. The study reports patient's demographics, tumor characteristics, operative details, and perioperative outcomes, using descriptive statistics of median and range values. Results: One hundred and one patients underwent RPN during the study period. Average tumor size was 3 (1.3-6.4) cm and average radius exophytic nearness anterior/posterior location (RENAL) score was 6 (4-10). Perioperative parameters were blood loss 200 (5-1500) ml and warm ischemia time 17 (8-40) minutes, excluding off-clamp surgery in 12 (11.9%); operative time was 166 (66-381) minutes. Conversion to open partial nephrectomy occurred in 9 (8.9%) patients, major complications in 3 (3%) patients, positive surgical margins in 5 (5%) patients, and the hospital stay was 4 (2-14) days. A total of 73 (73%) patients achieved a trifecta of freedom from any complication, negative surgical margins, and ischemia time ≤25 minutes. Study limitations included the retrospective design and small cohort size. Conclusions: The initial experience of robotic partial nephrectomy was associated with a surgical outcome comparable to that reported by higher-volume centers.

Upfront Nephrectomy Versus Preoperative Chemotherapy In Wilm's Tumour

BACKGROUND

Wilms tumour is the most common renal tumour in paediatric age group. This study was done to compare the two approaches used for treatment, namely upfront nephrectomy versus pre-operative chemotherapy..

METHODS

A descriptive cross-sectional study was done enrolling all the patients of Wilms tumour reporting to Oncology unit Children's Hospital during the study period. A total of 80 patients were divided into 2 groups. One group (n=40) had upfront surgery while the other (n=40) received pre-op chemotherapy before surgery. Both groups were compared for outcomes including whether treatment completed and declared cured, lost during treatment against medical advice, or died during treatment.

RESULTS

It was found that stage 2 patients were more likely to get upfront surgery done while stage 3, 4 and 5 were likely to get pre-operative chemotherapy before nephrectomy. Also, favourable histology was associated with better outcome overall outcome.

Time trends in service provision and survival outcomes for patients with renal cancer treated by nephrectomy in England 2000-2010

OBJECTIVE

To describe the temporal trends in nephrectomy practice and outcomes for English patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

Adult RCC nephrectomy patients treated between 2000 and 2010 were identified in the National Cancer Data Repository and Hospital Episode Statistics, and followed-up until date of death or 31 December 2015 (n = 30 763). We estimated the annual frequency for each nephrectomy type, the hospital and surgeon numbers and their case volumes. We analysed short-term surgical outcomes, as well as 1- and 5-year relative survivals.

RESULTS

Annual RCC nephrectomy number increased by 66% during the study period. Hospital number decreased by 24%, whilst the median annual hospital volume increased from 10 to 23 (P < 0.01). Surgeon number increased by 27% (P < 0.01), doubling the median consultant number per hospital. The proportion of minimally invasive surgery (MIS) nephrectomies rose from 1% to 46%, whilst the proportion of nephron-sparing surgeries (NSS) increased from 5% to 16%, with 29% of all T1 disease treated with partial nephrectomy in 2010 (P < 0.01). The 30-day mortality rate halved from 2.4% to 1.1% and 90-day mortality decreased from 4.9% to 2.6% (P < 0.01). The 1-year relative survival rate increased from 86.9% to 93.4%, whilst the 5-year relative survival rate rose from 68.2% to 81.2% (P < 0.01). Improvements were most notable in patients aged ≥65 years and those with T3 and T4 disease.

CONCLUSIONS

Surgical RCC management has changed considerably with nephrectomy centralisation and increased NSS and MIS. In parallel, we observed significant improvements in short- and long-term survival particularly for elderly patients and those with locally advanced disease.

Xanthogranulomatous pyelonephritis in adults: clinical, biological, radiological and therapeutic main findings in diffuse and focal forms. About 42 cases

INTRODUCTION

Xanthogranulomatous pyelonephritis (XGPN) is a particular form of chronic renal suppuration characterized by the destruction of renal parenchyma and its replacement by a granulomatous tissue containing xanthomatous cells.

OBJECTIVE

To report and describe the main clinical, biological, radiological and therapeutic aspects of xanthogranulomatous pyelonephritis in adults in focal and diffuse forms.

METHODS

This was a monocentric retrospective study involving 42 cases of XGPN operated and histologically confirmed between 2005 and 2015. We included in our study the patients belonging to any age, of both sexes, with a preoperative CT and whose XGPN diagnosis was confirmed histologically. Clinical, biological, bacteriological, radiological data and surgical procedures were collected and analyzed.

RESULTS

The mean age was 50 years (34-79) with a sex ratio of 0.61. The XGPN was diffuse in 88% and focal in 12% of cases. Clinical symptoms were dominated by low back pain (95%), fever (64%) and recurrent urinary tract infections (41%). Urine culture was positive in 67% of cases and Escherichia Coli was the most isolated germ (36%). 64% of patients had inflammatory anemia and 57% of patients had an inflammatory biological syndrome. Ultrasound and CT revealed obstruction of the urinary tract in all cases: a lithiasic cause in 90% of cases and the rest were isolated cases of retroperitoneal fibrosis, abnormal pyelo-ureteral junction, ureteral stenosis and pyelo-ureteric duplicity. A peri-renal abscess and / or psoas was associated in 6 cases (14%). The preoperative diagnosis was often pyonephrosis (50%). Neoplasia was suspected in 4 cases. The treatment consisted in a radical nephrectomy for all patients preceded by drainage of the excretory pathways in 41% of the cases and drainage of a collection in 21% of the cases.

CONCLUSION

The XGPN is a rare entity whose diagnosis is difficult. This is suspected on a cluster of clinical and biological arguments and can be evoked on the preoperative CT. The kidney cancer is the main differential diagnosis.

Nephrolithiasis in living kidney donor: experience of nephrologists

BACKGROUND

Living kidney donation for transplantation has become common practice. The decisions to accept a donor with nephrolithiasis are becoming frequent.

AIM

The aim of our study was to report our experience in the living donor kidney with asymptomatic lithiasis.

METHODS

Over a period of 4 years from 2009 to 2013 we collected 18 cases. From the clinical, metabolic and radiological data, we have determined the etiology of urolithiasis in our patients and established, after a literature review, a decision tree of kidney donation.

RESULTS

Our study included 10 women and 8 men with a mean age of 43 years. The nephrolithiasis was discovered incidentally during radiological assessment through the urinary tract without preparation in 1 case, the abdominal ultrasound in 6 cases and the abdominal CT scan in 11 cases. The donation of kidney in our study was performed in 1 case and disqualified in the others cases especially for metabolic abnormalities. In the single couple donor-recipient, after a follow up of 5 years; we have not identified adverse side effects either in the donor or in the recipient patient.

CONCLUSION

In living donors with nephrolithiasis the final decision of renal transplantation must be based on the confrontation between the clinical, biological and radiological data. Metabolic disorders constituted the mainly contraindication of kidney donation in our patients.

Worth a second look: outcomes of patients with initial finding of regular renal tissue in CT-guided renal tumor biopsies

INTRODUCTION AND OBJECTIVE

Renal tumor biopsy is recommended for histological diagnosis of radiologically indeterminate renal masses, to select patients with small-renal masses for surveillance approaches, before ablative treatments and to confirm metastatic spread of renal cell cancer (RCC), according to the EAU guidelines. We aimed to determine outcomes of patients with suspicious renal masses with initial finding of regular renal tissue in renal tumor biopsies.

METHODS

Retrospective database analysis of 101 patients undergoing CT-guided-, percutaneous renal tumor biopsies in local anesthesia.

RESULTS

In 23/101 patients, histopathologic evaluation of the biopsies showed regular renal tissue. Of these, two patients underwent simultaneous radiofrequency ablation (RFA), 2/23 underwent radical nephrectomy, despite negative biopsy because of radiological suspicious aspect. Overall, 12 patients underwent a second set of biopsies due to persistent clinical suspicion. Of these, five were diagnosed with RCC: three clear cell renal cell carcinoma (ccRCC) and two papillary renal cell carcinoma (pRCC). Benign tumours were found in two patients. A lymphoma was found in two patients. In 3/12 patients, also the second set of biopsies showed regular renal tissue.

CONCLUSION

An unsuspicious histology in CT-guided renal tumor biopsy does not preclude patients with suspicious renal masses from being diagnosed with malignancies.

The incidence of unsuccessful partial nephrectomy within the United States: A nationwide population-based analysis from 2003 to 2015

PURPOSE

Partial nephrectomy (PN) remains underutilized within the United States and few reports have attempted to explain this trend. The aim of this study is to evaluate the nationwide incidence of unsuccessful PN and factors that predict its occurrence.

METHODS

Using the Premier Healthcare Database, we retrospectively analyzed a weighted sample of 66,432 patients undergoing curative surgery for renal mass between 2003 and 2015. PN intent was denoted by presence of insurance claims for the administration of mannitol. Unsuccessful PN was defined as an event in which patients were administered mannitol but received radical nephrectomy. A multivariate logistic regression model was generated to identify factors predicting unsuccessful PN.

RESULTS

Overall rates of unsuccessful PN declined from 33.5% to 14.5% since 2003. Conversion to radical nephrectomy occurred most frequently during laparoscopic (34.7%) and least frequently during robotic approach (13.6%). There was significant difference in the rate of unsuccessful PN between very high and very low volume surgeons (open: 39.4% vs. 13.3%, laparoscopic: 51.2% vs. 32.2%, and robot assisted: 27.1% vs. 9.4%, all P<0.001). After adjustment for patient- and hospital-related factors, surgical approach (laparoscopic vs. open, odds ratio = 1.74, 95% CI: 1.31-2.30, P<0.001) and annual surgeon volume (very high vs. very low, odds ratio = 0.27, 95% CI: 0.21-0.34 P<0.001) were associated with unsuccessful PN.

CONCLUSIONS

Although the rate of unsuccessful PN appears to be declining, it still remains common for low volume surgeons and with the laparoscopic surgical approach. Further evaluation of its effect on health care outcomes is necessary.

[When is cytoreductive nephrectomy not beneficial for patients with metastatic renal cell carcinoma?]

Primary tumor resection in patients with synchronous metastatic renal cell carcinoma and a good performance status corresponds to a guideline recommendation which, however, is based on weak data from the era of cytokine therapy. This article presents arguments that weigh heavily against cytoreductive nephrectomy. From a molecular genetic viewpoint, the intervention eliminates only the easiest adversary but cannot prevent cancer-related death. Therefore, benefits and risks must be carefully and critically considered. Cytoreductive nephrectomy is not beneficial if treatment-induced morbidity will substantially affect the patient's quality of life and/or life expectancy or if the size and topography of the primary tumor renders it less dangerous than the metastases.

The Risk of Chronic Kidney Disease Associated with Urolithiasis and its Urological Treatments: A Review

PURPOSE

Urolithiasis can impair kidney function. This literature review focuses on the risk of kidney impairment in stone formers, the specific conditions associated with this risk and the impact of urological surgery.

MATERIALS AND METHODS

The PubMed® and Embase® databases were searched for publications on urolithiasis, its treatment, and the risk of chronic kidney disease, end stage renal disease and nephrectomy in stone formers.

RESULTS

In general, renal stone formers have twice the risk of chronic kidney disease or end stage renal disease, and for female and overweight stone formers the risk is even higher. Patients with frequent urinary tract infections, struvite stones, urinary malformations and diversions, malabsorptive bowel conditions and some monogenic disorders are at high risk for chronic kidney disease/end stage renal disease. Shock wave lithotripsy or minimally invasive urological interventions for stones do not adversely affect renal function. Declines in renal function generally occur in patients with preexisting chronic kidney disease or a large stone burden requiring repeated and/or complex surgery.

CONCLUSIONS

Although the effect size is modest, urolithiasis may cause chronic kidney disease and, thus, it is mandatory to assess patients with renal stones for the risk of chronic kidney disease/end stage renal disease. We suggest that all guidelines dealing with renal stone disease should include assessment of this risk.

Are we performing a lot of simple nephrectomies?

OBJECTIVE

To assess the frequency of simple nephrectomies for benign diseases and compare it with the frequency of nephrectomies for malignant diseases.

METHODS

The observational study was conducted at the Armed Forces Institute of Urology, Rawalpindi, Pakistan, from October 2008 to September 2011, and comprised patients undergoing simple nephrectomy for benign disease who were followed up for one year. This was compared to all the other urological procedures performed during the study period, including nephrectomies for malignant diseases. Indications and the post-operative sequel of simple nephrectomies were documented. SPSS 16 was used for data analysis.

RESULTS

Of the total 7518 procedures, 1995(26.5%) were open cases. A total of 295 nephrectomies were performed during this period, out of which 203 (68.8%) were simple nephrectomies for benign disease and 92 (31.1%) were radical nephrectomies for malignant causes. Simple nephrectomy (203 cases) represented 2.7% of the total and 26.5% of the open procedures. In contrast, the radical nephrectomies for malignant disease (92 cases) represented 1.2% and 4.6% respectively. Among the 203 cases of simple nephrectomy, the male-to-female ratio was 2.27:1 with 141(69.5%) males and 62(30.5%) females. The mean age was 40.21 + 17.243 years (range: 4-84 years) The most common indication of simple nephrectomy was non-functional kidney due to renal calculus disease 101(49.7%). This was followed by pelvi-ureteric junction obstruction causing renal damage 31(15.2%), chronic pyelonephritis 24(11.2%) and pyonephrosis 15(7.38%). Two (0.98%) patients had a fatal outcome..

CONCLUSIONS

The percentage of nephrectomies for benign diseases was more than the malignant diseases. Simple nephrectomies are being performed in a large percentage, indicating the advanced stage of benign diseases at the time of presentation.

[Preoperative prognostic factors and preoperative risk stratification of upper tract urothelial carcinoma]

OBJECTIVE

To identify the preoperative prognostic factors of upper tract urothelial carcinoma (UTUC) and construct preoperative risk stratification system.

METHODS

A retrospective study including 686 patients who were diagnosed with UTUC and received radical nephroureterectomy or partial ureterectomy in Peking University First Hospital during 2003 and 2013.

RESULTS

Of the 686 UTUC patients, 303 (44.2%) were male and 383 (55.8%) female. The postoperative pathological examination showed that 203 (29.6%) had high tumor stages (T3, T4), 300 (43.7%) had high tumor grades (G3) and 54 (7.9%) had lymph nodes metastasis (N1). After multivariate analysis, renal pelvic tumor, large tumor, estimated glomerular filtration rate (eGFR)≥30 mL/min, and male were associated with high tumor stage. Ureteral tumor, large tumor, and non-smoking history were associated with high tumor grade. Renal pelvis tumor, large tumor, and preoperative anemia were associated with positive N status. During the follow-up, 208 (30.3%) died for cancer and 210 (30.6%) developed intravesical recurrence. Multivariate analysis showed: large tumor (P=0.001), concomitant ipsilateral hydronephrosis (P=0.041), and preoperative anemia (P=0.001) were independently associated cancer-specific mortality after surgery, while ureteral tumor (P=0.04), multiple tumor (P=0.005), and high preoperative creatinine (P=0.036) were independent risk factors for intravesical recurrence.

CONCLUSION

Of the preoperative clinical parameters of UTUC patients, the large tumor, concomitant ipsilateral hydronephrosis, and preoperative anemia were independently associated with cancer-specific mortality after surgery. Ureteral tumor, multiple tumor, and high preoperative creatinine were independently associated with intravesical recurrence after surgery.

Postoperative 30-day Mortality Rates for Kidney Cancer Are Dependent on Hospital Surgical Volume: Results from a Norwegian Population-based Study

BACKGROUND

To improve cancer care in Norway, the government introduced surgical volume requirements for hospitals in 2015. To treat kidney cancer (KC) in Norway, the lower limit is 20 surgical procedures per year.

OBJECTIVES

To compare the impact of hospital volume on outcome with regard to 30-d mortality (TDM) following KC surgery.

DESIGN, SETTING, AND PARTICIPANTS

We identified all KC patients from the Cancer Registry of Norway diagnosed during 2008-2013 whose surgical treatment involved partial or radical nephrectomy. Hospitals were divided into three volume groups: low (LVH), intermediate (IVH), and high (HVH) volume.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relationships with outcome were analysed using multivariate logistic regression.

RESULTS AND LIMITATIONS

In total, 3273 patients were identified. The TDM rate was 0.89% overall, 0.73% for localised KC, and 2.6% for metastatic KC. The mean (median, interquartile range) numbers of procedures for LVH, IVH and HVH were 5.2 /yr (3, 1.3-8.7), 27 /yr (26, 23-30) and 53 /yr (53, 48-58), with TDM rates of 2.2%, 0.83%, and 0.39%, respectively (p=0.001). In a multivariate logistic regression model, tumour stage, age, and hospital volume remained independent TDM predictors. The odds ratio for TDM was 4.98 (confidence interval 1.72-14.4) for LVH compared to HVH (p=0.003). Study limitations include a lack of data for surgical complications and other possible confounders.

CONCLUSIONS

TDM is associated with age, stage, and hospital volume. The study supports the new regulation for hospital volume introduced in Norway.

PATIENT SUMMARY

The risk of dying within 30 d following kidney cancer surgery is low. Advanced disease and older age are risk factors for higher mortality. In this study, we also showed that more patients die within 30 d in hospitals performing fewer operations per year than in hospitals performing many operations.

Perioperative morbidity and long-term outcome of unilateral nephrectomy in feline kidney donors: 141 cases (1998-2013)

OBJECTIVE To evaluate the outcome associated with unilateral nephrectomy in feline kidney donors. DESIGN Retrospective case series. ANIMALS 141 cats. PROCEDURES Medical records of cats that underwent nephrectomy for renal donation were reviewed for information on signalment, date of renal donation, results of blood and urine analyses, infectious disease history, anesthetic protocols, intra- and postoperative complications, and postoperative analgesic protocols. Long-term follow-up data were obtained via client telephone interview and review of referring veterinarian medical records. RESULTS All donors were healthy young adult cats with a median age of 1.5 years (range, 0.8 to 2 years). No cats died or were euthanized during the perioperative period. Intraoperative complications occurred in 2 cats, and postoperative complications occurred in 17. Median time from nephrectomy to hospital discharge was 3.6 days (range, 2 to 8 days). Long-term follow-up information was available for 99 cats, with a median interval between nephrectomy and follow-up of 10 years (range, 0.25 to 15 years). Six cats had a history of urinary tract disease including stable chronic kidney disease (n = 3), acute kidney injury (2), and cystitis (1). Nine cats were dead at follow-up; death was attributed to chronic renal failure in 2 and acute ureteral obstruction in 4. CONCLUSIONS AND CLINICAL RELEVANCE Feline donor nephrectomy had an acceptably low perioperative morbidity in this series. Most cats (84%) for which follow-up information was available had no associated long-term effects. However, a small subset (7%) developed renal insufficiency or died of urinary tract disease.

[Prognostic factors of patients with T3N0M0 renal cell carcinoma: a single-center retrospective study of 182 patients]

OBJECTIVE

To evaluate the impacts of clinical, pathological, and laboratory factors on oncological outcomes of patients with T3N0M0 renal cell carcinoma.

METHODS

The clinical data, laboratory exam results, and follow-up outcomes of 182 patients with T3N0M0 renal cell carcinoma who underwent nephrectomy from 2007 to 2012 in Peking University First Hospital were retrospectively collected. The 5-year cancer-specific survival and 5-year recurrence-free survival of all the patients were calculated using Kaplan-Meier method, and the statistical significance between the survival curves were compared using the Log-rank test. Variables with significant differences in the univariate analysis were subjected to the multivariate analysis by Cox regression model. All the comparisons were conducted using two-tailed test and P<0.05 was considered statistically significant.

RESULTS

A total of 182 patients were included in this study. Of all the 182 patients, 126 were male (69.23%) and 56 were female (30.77%). The mean age was (56.75±12.45) years. The median follow-up time was 48 months (3-99 months). At the end of the follow-up, 50 patients (27.47%) died due to the disease after a median of 29.74 months and 59 patients (32.42%) had tumor recurrence after a median of 22.12 months. The 5-year cancer-specific survival of all patients was 68.30% (95% CI: 60.16%-75.84%); the 5-year recurrence-free survival was 60.70% (95% CI: 53.16%-68.84%). In the univariate analysis, diabetes mellitus, tumor invasion status, Fuhrman grade, serum album, serum cholestenone, anemia, and neutrophils percentage were associated with the cancer-specific survival and Fuhrman grade, serum album and anemia were associated with the recurrence-free survival. Variables with significant differences on univariate analysis were included in Cox multivariate regression analysis. Multivariate Logistic regression analysis showed that diabetes mellitus (HR=2.434, 95% CI: 1.243-4.769, P=0.010), hypoalbuminemia (HR=2.188, 95% CI: 1.074-1.074, P=0.031), and anemia (HR=3.320, 95% CI: 1.839-5.991, P<0.001) were independent risk factors significantly associated with cancer-specific survival; and higher Fuhrman grade (HR=2.552, 95% CI: 1.433-4.545, P=0.001), anemia (HR=2.535, 95% CI: 1.497-4.293, P=0.001) were independent factors significantly associated with recurrence-free survival.

CONCLUSION

Diabetes mellitus, hypoalbuminemia, and anemia were independent risk factors significantly associated with cancer-specific survival of T3N0M0 renal cell carcinoma patients; higher Fuhrman grade and anemia were independent risk factors significantly associated with tumor recurrence of T3N0M0 renal cell carcinoma patients.

Risk-adjusted outcomes in Medicare inpatient nephrectomy patients

Without risk-adjusted outcomes of surgical care across both the inpatient and postacute period of time, hospitals and surgeons cannot evaluate the effectiveness of current performance in nephrectomy and other operations, and will not have objective metrics to gauge improvements from care redesign efforts.We compared risk-adjusted hospital outcomes following elective total and partial nephrectomy to demonstrate differences that can be used to improve care. We used the Medicare Limited Dataset for 2010 to 2012 for total and partial nephrectomy for benign and malignant neoplasms to create prediction models for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day relevant readmissions. From the 4 prediction models, total predicted adverse outcomes were determined for each hospital in the dataset that met a minimum of 25 evaluable cases for the study period. Standard deviations (SDs) for each hospital were used to identify specific z-scores. Risk-adjusted adverse outcomes rates were computed to permit benchmarking each hospital's performance against the national standard. Differences between best and suboptimal performing hospitals defined the potential margin of preventable adverse outcomes for this operation.A total of 449 hospitals with 23,477 patients were evaluated. Overall AO rate was 20.8%; 17 hospitals had risk-adjusted AO rates that were 2 SDs poorer than predicted and 8 were 2 SDs better. The top performing decile of hospitals had a risk-adjusted AO rate of 10.2% while the lowest performing decile had 32.1%. With a minimum of 25 cases for each study hospital, no statistically valid improvement in outcomes was seen with increased case volume.Inpatient and 90-day postdischarge risk-adjusted adverse outcomes demonstrated marked variability among study hospitals and illustrate the opportunities for care improvement. This analytic design is applicable for comparing provider performance across a wide array of different inpatient episodes.

Perioperative blood transfusion predicts short term morbidity after nephrectomy

INTRODUCTION

To assess 30-day morbidity and mortality following partial nephrectomy (PN) and radical nephrectomy (RN) with relation to the administration of perioperative blood transfusions PBT).

MATERIALS AND METHODS

The National Surgical Quality Improvement Program was queried for patients with malignant renal tumors (International Classification of Diseases Ninth Revision codes 189-189.2) who underwent RN (Current Procedure Terminology codes 50220, 50225, 50230, 50234, 50236, 50545, 50546, 50548) or PN (50240, 50543) between 2005-2013. Patients were stratified by transfusion status and assessed for postoperative outcomes both separately and in composite, including morbidity, mortality, infectious complications, and pulmonary complications. Univariate and multivariate analyses were performed to identify significant independent predictors of these composite outcomes.

RESULTS

The overall transfusion rates were 15.8% and 8.2% for RN and PN, respectively. On multivariate analysis, PBT was associated with increased morbidity (RN: OR 2.147, 95% CI 1.687-2.733; PN: OR 2.081, 95% CI 1.434-3.022), mortality (RN: OR 2.308, 95% CI 1.159-4.598; PN: OR 5.166, 95% CI 1.207-22.12), infectious complications (RN: OR 1.656, 95% CI 1.151-2.383; PN: OR 1.945, 95% CI 1.128-3.354) and pulmonary complications (RN: OR 3.040, 95% CI 2.125-4.349; OR 3.771, 95% CI 2.108-6.746).

CONCLUSIONS

For patients undergoing RN or PN there is a significant association between receipt of PBT and 30-day postoperative outcomes, specifically overall morbidity, mortality, infectious complications, and pulmonary complications. The mechanism that underlies these effects has not been elucidated, but it most likely involves immunomodulation and acute lung injury. Future research should focus on formulating comprehensive transfusion guidelines for oncologic-related nephrectomies.

[Nephrectomies in poor or non-functioning kidneys. Is it the right thing to do?]

AIM OF THE STUDY

To review our management and outcomes of nephrectomies performed in patients with non-functioning kidneys.

METHODS

Retrospective analysis of the patients who underwent nephrectomy surgery in our hospital between 2010 and 2014. Data was collected from the patient charts paying special attention to the clinical resolution of the symptoms that motivated surgery.

MAIN RESULTS

A total of 18 nephrectomies were performed. Median age was of 6,5 years (range: 11 months to 15 years). Surgery was indicated by recurrent urinary tract infections (UTI) in 7 cases, renovascular hypertension (RHT) in 5, pain in 2, increasing size in 2 and parents' preference due to poor compliance with follow up in 2 patients. 16 nephrectomies were performed laparoscopically and 2 were open procedures. Median hospital length of stay was 48 hours. Complication rate was 5.55% both for the intraoperatively (1 case of bleeding) and post operatively (1 case of subcutaneous emphysema). Signs and symptoms were successfully resolved in all cases except for 3, 2 patients had an UTI and 1 persistent RHT.

CONCLUSIONS

Nephrectomy is a safe surgical procedure in children with a low rate of complications. An appropriate selection of the cases and a thorough preoperative multidisciplinary assessment are essential aspects to obtain good clinical results and to avoid post-operative complications.

Barriers to efficiency in robotic surgery: the resident effect

BACKGROUND

Robotic surgery offers advantages over conventional operative approaches but may also be associated with higher costs and additional risks. Analyzing surgical flow disruptions (FDs), defined as "deviations from the natural progression of an operation," can help target training techniques and identify opportunities for improvement.

MATERIALS AND METHODS

Thirty-two robotic surgery operations were observed over a 6-wk period at one 900-bed surgical center. FDs were recorded in detail and classified into one of 11 different categories. Procedure type, robot model, and resident involvement were also recorded. Linear regression analyses were used to evaluate the effects of these parameters on FDs and operative duration.

RESULTS

Twenty-one prostatectomies, eight sacrocolpopexies, and three nephrectomies were observed. The mean number of FDs was 48.2 (95% confidence interval [CI] 38.6-54.8 FDs), and mean operative duration was 163 min (95% CI 148-179 min). Each FD added 2.4 min (P = 0.025) to a case's total operative duration. The number and rate of FDs were significantly affected by resident involvement (P = 0.008 and P = 0.006, respectively). Resident cases demonstrated mostly training, equipment, and robot switch FDs, whereas nonresident cases demonstrated mostly equipment, instrument changes, and external factor FDs.

CONCLUSIONS

Although the FDs encountered in resident training are more frequent, they may not significantly increase operative duration. Other FDs, such as equipment or external factors, may be more impactful. Limiting these specific FDs should be the focus of performance improvement efforts.

[Social medicine assessment after surgical and targeted treatment of renal cell cancer]

In Germany, renal cell cancer counts for 2.5 % of all carcinomas in women and 3.5 % in men. Curative therapy ensures good chances of recovery. But there might be permanent complications like renal insufficiency, pain, incisional hernia, flank muscle relaxation, and paresis. In addition, targeted therapy is associated with several potential side effects. In both therapy groups, severe psychological problems may occur. Still employed patients with these problems must be examined by an expert to estimate the possibilities of returning to working (positive scope of work) and occupations which can not be performed anymore (negative scope of work).

National nephrectomy registries: Reviewing the need for population-based data

Nephrectomy is the cornerstone therapy for renal cell carcinoma (RCC) and continued refinement of the procedure through research may enhance patient outcomes. A national nephrectomy registry may provide the key information needed to assess the procedure at a national level. The aim of this study was to review nephrectomy data available at a population-based level in Australia and to benchmark these data against data from the rest of the world as an examination of the national nephrectomy registry model. A PubMed search identified records pertaining to RCC nephrectomy in Australia. A similar search identified records relating to established nephrectomy registries internationally and other surgical registries of clinical importance. These records were reviewed to address the stated aims of this article. Population-based data within Australia for nephrectomy were lacking. Key issues identified were the difficulty in benchmarking outcomes and no ongoing monitoring of trends. The care centralization debate, which questions whether small-volume centers provide comparable outcomes to high-volume centers, is ongoing. Patterns of adherence and the effectiveness of existing protocols are uncertain. A review of established international registries demonstrated that the registry model can effectively address issues comparable to those identified in the Australian literature. A national nephrectomy registry could address deficiencies identified in a given nation's nephrectomy field. The model is supported by evidence from international examples and will provide the population-based data needed for studies. Scope exists for possible integration with other registries to develop a more encompassing urological or surgical registry. Need remains for further exploration of the feasibility and practicalities of initiating such a registry including a minimum data set, outcome indicators, and auditing of data.

Nonclinical Factors Predict Selection of Initial Observation for Renal Cell Carcinoma

OBJECTIVE

To determine the rate of observation utilization over time and to identify factors influencing its use.

MATERIALS AND METHODS

Using the National Cancer Data Base, we studied observation utilization in patients diagnosed with localized renal cell carcinoma from 2003 to 2010. Relationships between temporal, demographic, provider, and clinical factors and the likelihood of observation were evaluated using multivariate logistic regression.

RESULTS

Of 109,410 analyzed patients, 7047 (6.4%) underwent observation with stable use over time (range, 6.1% to 6.8%). Patient and disease factors were the strongest predictors of observation. Specifically, the odds of biopsy were 1.8-11 times higher for elderly or comorbid patients and 1.6-8.4 times higher for small (clinical T1a), biopsied, or bilateral tumors (P <.01 for all). Racial and socioeconomic factors also significantly predicted observation usage. In particular, observation rates were higher among poor, African American, and uninsured or socially insured patients, with these groups having 1.2-3.5 times higher odds of observation (P <.01). Patients receiving care at community, low-volume, or nearby hospitals were also significantly more likely to undergo observation (P <.01).

CONCLUSION

Despite the continued rise in the incidence of incidental renal masses, initial observation use has remained stable. In accordance with treatment guidelines, observation is preferentially utilized in elderly and comorbid patients. However, nonclinical factors also predict observation use, suggesting that utilization may be influenced by racial and socioeconomic disparities in health care quality.

Rates of interventional procedures in patients with tuberous sclerosis complex-related renal angiomyolipoma

OBJECTIVE

To describe rates of renal artery embolization, partial nephrectomy, and complete nephrectomy in patients with tuberous sclerosis complex (TSC) and renal angiomyolipoma.

METHODS

Data from the MarketScan® Research Databases were used to select patients with TSC and renal angiomyolipoma during January 1, 2000-March 31,2013 (Commercial database) and January 1, 2000-June 30, 2012 (Medicaid database). Patients had at least 30 days of follow-up and were followed until the earliest of inpatient death, end of enrollment, or end of study. Rates of embolization and nephrectomy were calculated.

RESULTS

In total, 218 patients <18 years (mean = 9.7 years) and 378 patients ≥18 years (mean 36.9 years) were selected from the Commercial database. Fifty-nine patients <18 years (mean = 7.2 years) and 117 patients ≥18 years (mean = 37.2 years) were selected from the Medicaid database. Follow-up in the Medicaid cohorts was approximately twice that of the Commercial cohorts. Among patients in the study, 24.2% had at least one interventional procedure: 15.2% had embolization, 5.2% had partial nephrectomy, and 7.6% had complete nephrectomy. Within the Commercial cohort ≥18 years, 18.5% had embolization, 7.7% had partial nephrectomy, and 11.4% had complete nephrectomy. Corresponding percentages in the Medicaid adult cohort were 17.1%, 5.1%, and 4.3%. Repeat embolization procedures occurred in up to 7.7% of Commercial patients and in up to 6.8% of Medicaid patients. Repeat partial nephrectomy occurred in up to 4.5% and 1.7% of Commercial and Medicaid patients, respectively.

CONCLUSIONS

Approximately 25% of patients with TSC-renal angiomyolipoma experienced embolization or nephrectomy, with some patients undergoing repeat procedures. Study limitations included small sample sizes, the majority of the study period occurred prior to the approval of mammalian target of rapamycin inhibitors for the treatment of TSC-renal AML, and results may not be generalizable to patients with insurance other than commercial or Medicaid.

Impact of fellowship training on robotic-assisted laparoscopic partial nephrectomy: benchmarking perioperative safety and outcomes

To provide perioperative benchmark data for surgeons entering practice from formal robotic training and performing robotic-assisted laparoscopic partial nephrectomy (RAPN). Perioperative outcomes of the first 100 RAPN from a surgeon entering into practice directly from robotic fellowship training were analyzed. Postoperative complications were categorized by Clavien-Dindo grade. Surgical "trifecta scores" and Margin, Ischemia, and Complication (MIC) scoring were utilized to assess surgical outcomes. Statistical analyses were performed using SAS (version 9.2; SAS Institute, Inc., Cary, North Carolina). Median age of the cohort was 63 years (22-81 years), and 34 (34.3%) patients were over age 65. Forty-one (41.4%) patients had a BMI > 30. Thirteen (13.1%) had RENAL 10-12 tumors, 22 of which (22.2%) were >4 cm in size. Median warm ischemia time was 17 min, and 13 patients had resection without warm ischemia. Five patients were converted to open partial nephrectomy, and 1 patient was converted to laparoscopic nephrectomy. Twenty-one patients (21.2%) experienced a complication, 6 of whom had a major (Clavien grade 3 or higher) complication with one grade 5 complication. Operating room time decreased with experience, but surgical complications and hospital stay did not change with experience. MIC score of renal cell carcinoma (RCC) patients was 74.7%, while the surgical trifecta was reached in 71.3 % of RCC patients. Surgeons may enter practice directly from formal robotic training and perform RAPN with perioperative outcomes, surgical complications, surgical trifecta scores, and MIC scoring in line with those the most experienced robotic partial nephrectomists.

Readmissions after major urologic cancer surgery

INTRODUCTION

We examine the incidence and predictors of readmission after major urologic cancer surgery using a national, prospective-maintained database specifically developed to assess quality of surgical care.

MATERIALS AND METHODS

Patients undergoing major urologic cancer surgery (radical prostatectomy [RP], radical nephrectomy [RNx], partial nephrectomy [PNx]), radical cystectomy [RC]) in 2011 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) using Current Procedural Terminology (CPT) codes. Those readmitted within 30 days after surgery were identified. Multivariable logistic regression models examined the association between patient characteristics and the odds of readmission.

RESULTS

Overall, we identified 5356 RP, 1301 RNx, 918 PNx and 623 RC patients, of which 206 (3.8%), 533 (6.8%), 348 (6.3%) and 129 (20.7%) were readmitted within 30 days respectively. Independent predictors of readmission for RP included age (Odds Ratio [OR]: 1.02, p = 0.02), American Society of Anesthesiology (ASA) score 3-5 (versus 1-2, OR: 1.35, p = 0.04), smoking status (OR: 1.53, p = 0.04), and the occurrence of wound complications (OR: 9.31, p < 0.001), thromboembolic (OR: 14.7, p < 0.001), and renal failure (OR: 1.62, p = 0.01) complications during the index hospitalization. For RC patients, the only predictor of readmission was age (OR: 0.98, p = 0.04). Predictors of readmission for RNx included higher ASA score (OR: 1.77, p = 0.03), and the presence of any complications during the index hospitalization (OR: 2.21, p = 0.03).

CONCLUSIONS

Several patient characteristics have a significant impact on the risk of 30 day readmission after major urologic cancer surgery. Our data suggests that improving prevention and management of complications during the index hospitalization may lead to a substantial decrease in readmission rates.

Quality of life survey following laparoscopic and open radical nephrectomy

PURPOSE

To compare the quality of life (QoL) of renal cancer patients following laparoscopic and open radical nephrectomy.

MATERIALS AND METHODS

Seventy-two (64.9%) patients who were treated with open radical nephrectomy (ORN group) and 39 (35.1%) patients who were treated with laparoscopic radical nephrectomy (LRN group) were included in this study. QoL was evaluated by Short Form-36 (SF-36) physical domain scores obtained before surgery, 1 and 6 months after surgery. Analgesic requirement and visual analog scale (VAS) pain scores following surgeries were recorded.

RESULTS

The demographic features of the groups were similar. There was a significant difference in tumor size be­tween the ORN group (71.59 & plusmn; 29.83 mm) and LRN group (57.08 & plusmn; 19.33 mm) (P = .011). In the LRN group there was less blood loss, a lower transfusion rate, earlier ambulation, more rapid convalescence and shorter hospitalization; however, the difference in surgical duration between the ORN group (122.86 & plusmn; 36.8 min) and LRN group (140.17 & plusmn; 50.71 min) was not significant (P = .383). Analgesic requirement and VAS pain scores were similar in both groups. In terms of SF-36 physical domain scores, the general health perception score in the LRN group was higher than that in the ORN group at pre-surgery, 1 and 6 months after surgery. SF-36 physical functioning and general health perception scores in both groups were significantly lower in 1 month after surgery and were higher in 6 months after surgery, as compare to before surgery. Bodily pain scores in LRN group did not change significantly after surgery (P = .376).

CONCLUSION

LRN exhibited some technical advantages, including less blood loss, shorter hospitalization and more rapid recovery. Although the ORN patients had relatively larger tumors, analgesic requirement, postoperative complications, body pain, and physical functioning weren't significantly different between the groups. QoL was higher 6 months after surgery than before surgery in both groups. & nbsp;

Trends in surgical management of T1 renal cell carcinoma

Historically, open radical nephrectomy (ORN) represented the standard of care for localized renal cell carcinoma (RCC). While the incidence of T1 RCC is rising, treatment options are developing fast and the standard of care according to European and American guidelines has changed to partial nephrectomy (PN), or laparoscopic radical nephrectomy in patients not suitable for PN. To assess the implementation of guideline recommendations and to profile recent surgical and technical innovations, we reviewed the current literature. We observed that ORN still represents the most commonly used treatment in T1 RCC patients. Utilization of PN increased over time but implementation is still in progress. Whereas PN is frequently used in tertiary care centers, population-based studies suggest discrepancies in the diffusion of standard of care treatments. Alternative minimally invasive approaches for PN are available but their superiority is not yet proven. Further efforts in improving the training of urologic surgeons are required to continue the implementation of guideline recommendations.

Oncologic outcomes of laparoscopic nephroureterectomy for pT3 upper urinary tract urothelial carcinoma

AIM

We present the oncologic outcomes of laparoscopic nephroureterectomy management of pT3 upper urinary tract urothelial carcinoma.

METHODS

Between October 2003 and January 2011, 50 patients with pT3 upper urinary tract urothelial carcinoma which had pathologically confirmed underwent laparoscopic nephroureterectomy at our institution. Demographic data, perioperative results, pathological findings and oncologic outcomes were reviewed and analyzed retrospectively.

RESULTS

There were 36 patients (72%) of high grade lesion and 14 patients (28%) of low grade lesion. Lymphovascular invasion was observed in 16 patients (32%) and the surgical margin was positive in one patient. N stage was pN0 in 16 (32%), pN1 in 3 (6%), pN2 in 1 (2%) and pN3 in 1 (2%). The 5-year overall survival rate was 52.6% and the 5-year cancer-specific survival rate was 65.3%. Overall recurrence developed in 23 patients. There were 10 patients (20%) of urothelial recurrence which were all occurred in the bladder at the mean period of 13.6 months, and 7 patients of them were invasive bladder cancer. There were 16 patients (32%) of non-urothelial recurrence developed at the mean period of 9.69 months. On multivariate analyses lymphadenopathy and lymph node involvement of cancer (N+) were identified as independent predictive factors for the cancer-specific survival, and concomitant bladder tumor, grade and lymphovascular invasion were identified as independent predictive factors for the overall recurrence free survival.

CONCLUSION

Laparoscopic nephroureterectomy in patients with high stage upper urinary tract urothelial carcinoma appear comparable to those of open surgery in the regard of oncologic outcomes.

[Controversies of partial nephrectomy for renal cell carcinoma : survey in the German-speaking countries]

BACKGROUND

The goal of this study was to evaluate how partial nephrectomy is technically performed in Germany, Austria, and Switzerland.

METHODS

A one-page anonymous questionnaire was designed to evaluate the indication, the technical procedure, and the follow-up of R1 situation after partial nephrectomy. Furthermore, the size of the hospitals and their catchment areas were recorded. The questionnaire was sent to 341 clinics and a statistical analysis was performed.

RESULTS

The response rate was 69 %. Up to 99 % of the clinics also perform partial resection in T1b tumors. Of those responding, 58 % perform this surgery laparoscopically, and 83 % of the surgeries are performed in warm ischemia. For the follow-up, 29 % suggest imaging within the first 6 weeks. According to this survey, maximum care clinics perform laparoscopic nephrectomy more frequently (p = 0.003).

CONCLUSION

The survey of 236 hospitals performing partial nephrectomy shows great variability in the indication, technique, and aftercare of organ-preserving renal tumor surgery. It also shows that a large proportion of tumors >4 cm undergo organ-preserving surgery, many of them minimally invasive. The diverse handling with positive instantaneous section and R1 results suggest the need for further studies concerning long-term follow-up after minimally invasive surgery with R1 situation and renal tumors > T1a.

Utilization of cytoreductive nephrectomy and patient survival in the targeted therapy era

We sought to analyze utilization and survival outcomes of cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (RCC) before and after introduction of targeted therapy. We identified patients with metastatic RCC between 1993 and 2010 in the SEER registry and examined temporal trends in utilization. We performed a joinpoint regression to determine when changes in utilization of CN occurred. We fitted multivariable proportional hazard models in full and propensity score-matched cohorts. We performed a difference-in-difference analysis to compare survival outcomes before and after introduction of targeted therapy. The proportion of patients undergoing CN increased from 1993 to 2004, from 29% to 39%. We identified a primary joinpoint of 2004, just prior to the introduction of targeted therapy. Beginning in 2005, there was a modest decrease in utilization of CN. CN was associated with a lower adjusted relative hazard (0.41, 95% confidence interval 0.34–0.43). Median survival among patients receiving CN increased in the targeted therapy era (19 vs. 13 months), while median survival among patients not receiving CN increased only slightly (4 vs. 3 months). Difference-in-difference analysis showed a significant decrease in hazard of death among patients who received CN in the targeted therapy era. Despite decreased utilization in the targeted therapy era, CN remains associated with improved survival. Prospective randomized trials are needed to confirm the benefit of CN among patients with metastatic RCC treated with novel targeted therapies.

[Practice uptake in France before and after the 2010 French guidelines on kidney cancer]

INTRODUCTION AND OBJECTIVE

Compared to the 2007 edition, the 2010 French urological association onco-urology guidelines boarded the indications of partial nephrectomy (PN) as long as the procedure is technically feasible. The aim of this study was to assess national practice with respect to kidney surgery in the 2 years before and after current guidelines.

MATERIALS AND METHODS

The national database of the Agence Technique de l'Information sur l'Hospitalisation (ATIH) was queried for procedures performed between 2009 and 2010 (era 1) and between 2011 and 2012 (era 2). The coding system of the Classification Commune des Actes Médicaux (CCAM) was used to extract kidney related procedures. For each era, procedures were sorted into partial versus radical nephrectomy (RN), laparoscopic/robotic versus open approach, and private versus public hospital. The two eras were then compared.

RESULTS

Overall, 28,000 and 28,907 procedures were reported in era 1 and 2 with mean 14,000 and 14,450 procedures per year respectively. PN increased from 30% to 35% (P<0.0001) between the two eras. This uptake was similar in public and private hospitals. Accordingly, laparoscopic/robotic approach has significantly increased between the two eras (35% versus 39%, P<0.0001) and even more importantly in public hospitals (P=0.0017). There was a significant increase in laparoscopic/robotic PN as well as a decrease in open RN over the years of the study period.

CONCLUSION

This study showed the development of PN and the minimally invasive approach. Over the study period, minimally invasive procedure uptake was higher in public hospitals.