Abstract
BackgroundThere are limited data concerning patients treated with sequential bilateral kidney surgery. Current guidelines still lack an optimal surgical sequencing approach. We evaluated renal functional outcomes after sequential partial nephrectomy (PN) and radical nephrectomy (RN) in patients with bilateral renal cell carcinoma (RCC).MethodsA propensity score matched cohort of 267 patients (synchronous bilateral RCCs, N = 44 [88 lesions]; metachronous bilateral, N = 45 [90 lesions]; unilateral, N = 178) from two tertiary institutions were retrospectively analyzed. Synchronous bilateral RCCs were defined as diagnosis concomitantly or within 3 months of former tumor. Renal functional outcomes were defined as estimated glomerular filtration rate (eGFR) changes and de novo chronic kidney disease (CKD, stage ≥3) after surgery. Renal functional outcomes and clinical factors predicting de novo CKD were assessed using descriptive statistics and Cox regression analysis.ResultsIn subgroup of bilateral RCCs, patients underwent sequential PN (N = 48), PN followed by RN (N = 8), or RN followed by PN (N = 25). Final postoperative estimated glomerular filtration rates (eGFRs) were 79.4, 41.4, and 61.2 ml/minute/1.73 m2, respectively (p = 0.003). There were significant differences in eGFR decline from baseline and de novo chronic kidney disease (CKD stage ≥ III) among groups, with PN followed by RN group showing the worst functional outcomes (all p < 0.05). Moreover, sequential PN subgroup in bilateral RCC showed significantly higher rate of de novo CKD than unilateral RCC group (13.8% vs. 6.9%, p = 0.016). On multivariate analysis, hypertension (p = 0.010) and surgery sequence (PN followed by RN, p < 0.001) were significant predictors of de novo CKD.ConclusionsThe surgery sequence should be prudently determined in bilateral renal tumors. PN followed by RN showed a negative impact on renal functional preservation. Nephron-sparing surgery should be considered for all amenable bilateral RCCs.
Highlights
It has been estimated that 73,800 new cases of cancers of the kidney and renal pelvis will be diagnosed in the United States in 2020 and that 14,800 people will die of them [1]
In the bilateral renal cell carcinoma (RCC) cohort, subgroup comparative analysis for renal functional outcome (PN followed by partial nephrectomy (PN) vs. PN followed by radical nephrectomy (RN) vs. RN followed by PN group) was conducted (Table 2)
There were significant differences in estimated glomerular filtration rate (eGFR) decline from baseline and de novo Chronic kidney disease (CKD) among groups, with PN followed by RN group showing the worst functional outcomes
Summary
It has been estimated that 73,800 new cases of cancers of the kidney and renal pelvis will be diagnosed in the United States in 2020 and that 14,800 people will die of them [1]. 85% of all kidney tumors are renal cell carcinoma (RCC). Due to the relative rarity of bilateral presentation, even until now, there are limited data in the literature concerning patients treated with sequential bilateral kidney surgery. Few literatures have evaluated the functional impact of bilateral kidney surgery and how functional outcomes are influenced by tumor characteristics, modality selection, and patient-related risk factors [6,7,8,9]. Several studies have elucidated renal functional outcomes in patients with bilateral synchronous tumors who have undergone sequential bilateral kidney surgery. There are limited data concerning patients treated with sequential bilateral kidney surgery. We evaluated renal functional outcomes after sequential partial nephrectomy (PN) and radical nephrectomy (RN) in patients with bilateral renal cell carcinoma (RCC)
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