Clinical T1b Research Articles

Robot assisted laparoscopic retroperitoneal lymph node dissection in testicular tumor

Sir, We read with interest the recently published article by Dogra et al. in your journal.[1] The authors present a nice description of their right sided robotic-laparoscopic assisted retroperitoneal lymph node dissection (RPLND) for a clinical stage T1b non-seminomatous germ cell testicular. Although the open procedure is still considered the gold standard, the robotic assisted laparoscopic procedure, from a technical standpoint and the focus of this discussion, has proven its feasibility and allows for better instrument control and maneuverability compared with traditional laparoscopic procedure.[2] Patient selection is paramount, as those patients with large masses or extensive involvement of the major vessels or adjacent organs would be a better candidate for an open procedure. The laparoscopic RPLND failed to gain wide-spread acceptance due to the advanced laparoscopic techniques required to perform the procedure.[3] The robotic assisted procedure overcomes several of these limiting factors, therefore reducing the challenge of the procedure and promising results with decreased bowel injury, faster convalescence and improved overall quality of life. With regards to the authors’ issues with the third robotic arm (crossing over and collision), we recommend a linear port placement and a 90° robotic docking, which allows for full range of motion of all the robotic arms. This also improves the range of surgical accessibility within the patient for a meticulous and safe dissection.[24] There continues to be a need for further discussion and time to allow for data series to mature and foster a more fruitful discussion to expand the role of the robotic-assisted laparoscopic RPLND in clinical stage T1 patients. We appreciate the authors’ contribution to this discussion.

Zonal NePhRO Scoring System: A Superior Renal Tumor Complexity Classification Model

BackgroundSince the advent of the first standardized renal tumor complexity system, many subsequent scoring systems have been introduced, many of which are complicated and can make it difficult to accurately measure data end points. In light of these limitations, we introduce the new zonal NePhRO scoring system. Patients and MethodsThe zonal NePhRO score is based on 4 anatomical components that are assigned a score of 1, 2, or 3, and their sum is used to classify renal tumors. The zonal NePhRO scoring system is made up of the (Ne)arness to collecting system, (Ph)ysical location of the tumor in the kidney, (R)adius of the tumor, and (O)rganization of the tumor. In this retrospective study, we evaluated patients exhibiting clinical stage T1a or T1b who underwent open partial nephrectomy performed by 2 genitourinary surgeons. Each renal unit was assigned both a zonal NePhRO score and a RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior, location relative to polar lines) score, and a blinded reviewer used the same preoperative imaging study to obtain both scores. Additional data points gathered included age, clamp time, complication rate, urine leak rate, intraoperative blood loss, and pathologic tumor size. ResultsOne hundred sixty-six patients underwent open partial nephrectomy. There were 37 perioperative complications quantitated using the validated Clavien-Dindo system; their occurrence was predicted by the NePhRO score on both univariate and multivariate analyses (P = .0008). Clinical stage, intraoperative blood loss, and tumor diameter were all correlated with the zonal NePhRO score on univariate analysis only. ConclusionThe zonal NePhRO scoring system is a simpler tool that accurately predicts the surgical complexity of a renal lesion.

Hilar clamping versus off-clamp laparoscopic partial nephrectomy for T1b tumors

An off-clamp, or zero-ischemia, approach to laparoscopic partial nephrectomy has been a proposed means of preserving global renal function by preventing ischemia to normal renal parenchyma. However, for clinical stage T1b tumors this provides a unique challenge as the large size of these tumors further complicates an already difficult procedure. This review provides an overview of outcomes for laparoscopic partial nephrectomies performed with or without hilar clamping for clinical stage T1b tumors. There is a paucity of data for laparoscopic partial nephrectomies for this larger tumor size. The feasibility of performing laparoscopic partial nephrectomy for renal tumors 4-7 cm in size has clearly been demonstrated. Not unexpectedly, using an off-clamp technique during laparoscopic partial nephrectomy has variably shown increased intraoperative blood loss when compared to hilar controlled procedures. This does not, however, seem to translate into increased risk of transfusion or loss of visualization leading to compromise in oncologic outcomes. Lastly, some data suggest improved short-term and long-term preservation of renal function as estimated by estimated glomerular filtration rate. With accumulating data pointing to the long-term health benefits of nephron sparing surgery over radical nephrectomy and its oncologic equivalency confirmed, there is an increased push to perform partial nephrectomy for larger tumors. As demonstrated in the setting of a solitary kidney, every minute of warm ischemia counts and ischemia is an important modifiable variable that impacts renal function. As such, off-clamp dissection has potential advantages. The reviewed data show that foregoing hilar clamping for T1b tumors is not only feasible, but is likely beneficial with respect to renal function and does not appear to carry an increased risk of transfusion despite increased blood loss.

Image Based Feasibility of Renal Sparing Surgery for Very Low Risk Unilateral Wilms Tumors: A Report from the Children’s Oncology Group

Nephrectomy with lymph node sampling is the recommended treatment for children with unilateral Wilms tumor under the Children's Oncology Group protocols. Using radiological assessment, we determined the feasibility of performing partial nephrectomy in a select group of patients with very low risk unilateral Wilms tumor. We reviewed imaging studies of 60 patients with a mean age of less than 2 years with very low risk unilateral Wilms tumor (mean weight less than 550 gm) to assess the feasibility of partial nephrectomy. We evaluated percentage of salvageable parenchyma, tumor location and anatomical features preventing a nephron sparing approach. A linear relationship exists between tumor weight and computerized tomography estimated tumor volume. Mean tumor weight in the study population was 315 gm. Partial nephrectomy was deemed feasible in only 5 of 60 patients (8%). When considering a select population with very low risk unilateral Wilms tumor (lower volume tumor), only a small percentage of nonpretreated patients are candidates for nephron sparing surgery.

Expanding utilization of robotic partial nephrectomy for clinical T1b and complex T1a renal masses

Partial nephrectomy is the standard of care for cT1a renal masses, offering equivalent oncologic outcomes and lower renal function impairment when compared to radical nephrectomy, with excellent overall survival results. Robot-assisted partial nephrectomy (RAPN) allows to perform a precise tumor excision, simplifying the reconstruction steps of the procedure, especially in the treatment of complex or large renal tumors. Aim of this study was to summarize the available perioperative, functional, and oncological outcomes of RAPN performed for complex and/or large (cT1b) renal cell carcinoma (RCC). We performed a nonsystematic review of the literature using a free-text protocol in the Medline database, using the terms "robot-assisted partial nephrectomy" and "robotic partial nephrectomy." Two Authors reviewed separately to select RAPN series reporting data about complex and cT1b RCC. Other significant studies cited in the reference lists of the selected papers were also evaluated. According to the currently available evidences, RAPN offers promising results in terms of perioperative, functional, and oncological outcomes for the conservative management of complex or large renal tumors, even when compared with open and laparoscopic partial nephrectomy. Robot-assisted procedure allows surgeons to treat large and challenging renal masses, even if with higher warm ischemia time, operating time, and estimated blood loss in comparison with those obtained for the treatment of smaller lesions. In the hands of experienced surgeons, RAPN is a safe and reproducible approach for the treatment of cT1b and more challenging renal tumors, and could represent the way to expand the indications for minimally invasive conservative approach to RCC.

1199 RADIOFREQUENCY ABLATION ACHIEVES COMPARABLE LOCAL ONCOLOGICAL CONTROL TO PARTIAL NEPHRECTOMY FOR T1 RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Localized1 Apr 20131199 RADIOFREQUENCY ABLATION ACHIEVES COMPARABLE LOCAL ONCOLOGICAL CONTROL TO PARTIAL NEPHRECTOMY FOR T1 RENAL CELL CARCINOMA Sarah Psutka, W. Scott McDougal, Douglas Dahl, Francis McGovern, Peter Mueller, Debra Gervais, and Adam Feldman Sarah PsutkaSarah Psutka Boston, MA More articles by this author , W. Scott McDougalW. Scott McDougal Boston, MA More articles by this author , Douglas DahlDouglas Dahl Boston, MA More articles by this author , Francis McGovernFrancis McGovern Boston, MA More articles by this author , Peter MuellerPeter Mueller Boston, MA More articles by this author , Debra GervaisDebra Gervais Boston, MA More articles by this author , and Adam FeldmanAdam Feldman Boston, MA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2553AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radiofrequency ablation (RFA) of small renal masses (SRM) is increasingly offered to select patients with significant comorbidity as an alternative, less invasive, nephron−sparing (NS) therapy. Long−term comparisons of oncologic efficacy between RFA and partial nephrectomy (PN), the current gold standard for T1 renal cell carcinoma (RCC), are lacking. Our objective was to compare long−term oncologic outcomes between patients with clinical T1a and T1b RCC treated with either RFA or PN. METHODS 551 patients underwent NS treatment for SRM between 1998 and 2008. In general, patients selected for RFA had substantial medical comorbidity, were poor surgical candidates, and/or had a projected life-expectancy of less than 10 yrs. Exclusion criteria for this study included history of RCC, multiple synchronous tumors, metastatic disease at presentation, genetic predisposition to RCC, or non−RCC pathology. A total of 380 patients were included in this analysis, including 186 patients who underwent RFA and 194 patients who underwent PN. All patients undergoing RFA had biopsy−proven RCC. Primary endpoints included recurrence−free survival (RFS) and overall survival (OS). RESULTS The mean (range) follow−up for RFA and PN were 4.8 years (0.5−13.1) and 5.4 years (0.5−12.8). Patients undergoing RFA were more likely to have larger tumors (3.1 vs. 2.6 cm, p<0.0001), be older (71.1 vs. 57.4 years, p<0.0001), and have a higher Charlson comorbidity score (5.6 vs. 3.5, p<0.0001). Of the 194 patients undergoing PN, 17 had positive margins (8.8%) and 14 had pT3a disease (7.2%). There were 12 local recurrences (6.5%) after RFA compared to 6 (3.1%) after PN (p=0.12) with mean time to recurrence of 6.3 years for RFA vs. 2.7 years for PN. Statistically, there was no significant difference in RFS between RFA and PN (Figure 1, p=0.07). Overall survival was higher in the PN group (5.2% vs.17.8%, p<0.0001), as was expected given the increased comorbidity and advanced age of patients in the RFA cohort. Death from RCC occurred in 4 patients treated by RFA and 1 treated with PN (p = 0.15). CONCLUSIONS RFS and cancer−specific mortality were comparable following RFA or PN for cT1a and cT1b RCC. For carefully selected patients with significant comorbidity precluding surgical intervention, RFA appears to provide durable oncological control for cT1 RCC in a nephron−sparing manner. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e491 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sarah Psutka Boston, MA More articles by this author W. Scott McDougal Boston, MA More articles by this author Douglas Dahl Boston, MA More articles by this author Francis McGovern Boston, MA More articles by this author Peter Mueller Boston, MA More articles by this author Debra Gervais Boston, MA More articles by this author Adam Feldman Boston, MA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Elective nephron sparing surgery in clinical T1b renal cell carcinoma

Objective To investigate the safety and feasibility of elective nephron sparing surgery (NSS) in clinical T1b (4-7 cm) renal cell carcinoma (RCC).Methods From January 2005 to Decem-ber 2008,elective NSS was carried out in 30 (19 males,11 females,mean age 56 years,from 39 years to 74 years) asymptomatic,single sited,peripheral,and organ confined RCCs,and the mean tumor size was 5.4 cm (4.2-7.0 cm).Intraoperative frozen section analysis was routinely used in suspect areas.A single urologist carried out the major surgical procedure.Peritumoral margin was 0.5 cm for the cortex and 0.2 cm for the deep part.Maximal diameter of the tumor divided by the maximal diameter of affected kidney (9.6-12.6 cm,mean 11.4 cm) in thin-layer CT scan or MRI was calculated as the relative tumor size (0.38-0.47,mean 0.43).Surgical parameters,pathological characters and clinical outcomes were documented and analyzed.Results Only 1 case was converted to radical nephrectomy due to uncontrollable bleeding during operation.For the rest 29 successful NSSs,median warm ischemia was 17 min (14-30 min) ; median blood lose was 40 ml (20-100 ml),no transfusion needed.All the 30 patients,including 26 clear cells,2 papillary and 2 chromophobe carcinomas,were pathologically confirmed to be T1b.The serum creatinine levels 3 months after operation were similar with those before operation.After a median follow-up of 56 months (36-72 months),all the 30 patients survived without recurrence.Conclusions Elective NSS in clinical T1b renal cell could be effective and safe.Location and relative tumor size should also be taken into account in addition to other ordinary indications. Key words: Kidney neoplasms; Carcinoma; Nephron sparing surgery

The Management of a Clinical T1b Renal Tumor in the Presence of a Normal Contralateral Kidney

The Management of a Clinical T1b Renal Tumor in the Presence of a Normal Contralateral Kidney

10-Year Oncologic Outcomes After Laparoscopic and Open Partial Nephrectomy

Open partial nephrectomy has proven long-term oncologic efficacy. Laparoscopic partial nephrectomy outcomes at 5 to 7 years of followup appear comparable to those of the open approach. We present the 10-year outcomes of patients who underwent laparoscopic or open partial nephrectomy for a single clinical stage cT1 7 cm or less renal cortical tumor. Of 1,541 patients treated with partial nephrectomy for a single cT1 tumor between 1999 and 2007 with a minimum 5-year followup, an actual followup of 10 years or greater was available in 45 and 254 after laparoscopic and open partial nephrectomy, respectively. Median followup after laparoscopic and open surgery was 6.6 and 7.8 years, respectively. At 10 years the overall survival rate was 77.2%. The metastasis-free survival rate was 95.2% and 90.0% after partial nephrectomy for clinical T1a and T1b renal cell carcinoma, respectively (p <0.0001). Baseline differences between patients treated with laparoscopic and open partial nephrectomy accounted for most observed differences between the cohorts. The median glomerular filtration rate decrease was 16.9% after the laparoscopic approach and 14.1% after the open approach (p = 0.5). On multivariable analysis predictors of all cause mortality included advancing age (HR 1.52/10 years, p <0.0001), comorbidity (HR 1.33/1 U, p <0.0001), absolute indication (HR 2.25, p = 0.003) and predicted recurrence-free survival (HR 1.58/10% increased risk, p = 0.004) but not laparoscopic vs open operative approach (p = 0.13). Similarly, predictors of metastasis included absolute indication (HR 4.35, p <0.0001) and predicted recurrence-free survival (HR 2.67, p <0.0001) but not operative approach (p = 0.42). The 10-year outcomes of laparoscopic nephrectomy and open partial nephrectomy are excellent in carefully selected patients with limited risk of recurrence for cT1 renal cortical tumors. Overall survival at 10 years is mediated by patient factors such as age, comorbidity and operative indication, and by cancer factors such as predicted recurrence-free survival but not by the choice of operative technique, which depends on surgeon preference and experience.

Surgically Induced Chronic Kidney Disease May be Associated with a Lower Risk of Progression and Mortality than Medical Chronic Kidney Disease

Chronic kidney disease from medical causes is present in 25% to 30% of patients before surgery for renal cancer. Although chronic kidney disease due to medical causes is typically associated with a 2% to 5% annual renal functional decline and decreased overall survival, reduced glomerular filtration rate occurring only after surgery may not have the same negative consequences. All patients undergoing surgery for suspected renal malignancy were identified in an institutional registry. Median clinical followup was 6.6 years. Of 4,180 patients 28% had a preoperative glomerular filtration rate of less than 60 ml/minute/1.73 m(2) (chronic kidney disease due to medical causes) and in 22% the glomerular filtration rate decreased to less than 60 ml/minute/1.73 m(2) only after surgery (surgically induced chronic kidney disease). Preoperative glomerular filtration rate was a strong predictor of overall survival on univariable and multivariable analysis. The risk of death after renal surgery was 1.8, 3.5 and 4.4-fold higher in patients with preoperative chronic kidney disease stages 3, 4 and 5, respectively, vs normal preoperative glomerular filtration rate. Average overall loss of renal function was 23%, including 13% within 90 days after surgery and 3.5% annually thereafter. Postoperative glomerular filtration rate only predicted survival for patients with preexisting chronic kidney disease due to medical causes. Neither surgically induced chronic kidney disease nor postoperative glomerular filtration rate was a significant predictor of survival in patients without preexisting chronic kidney disease due to medical causes. Annual renal functional decline was 4.7% and 0.7% for patients with chronic kidney disease due to medical causes and surgically induced chronic kidney disease, respectively, with a greater than 50% reduction in glomerular filtration rate in 7.3% and 2.2%, respectively (p <0.0001). Annual renal functional decline greater than 4.0% was associated with a 43% increase in mortality (p <0.0001). Surgically induced chronic kidney disease is associated with a relatively low risk of progressive renal functional decline and impact on survival does not appear to be substantial during intermediate term followup. In contrast, preoperative chronic kidney disease due to medical causes places patients at increased risk, indicating nephron sparing surgery for such patients.

Modified transperitoneal laparoscopic radical prostatectomy : clinical study of 285 cases

Objective To evaluate the technique and clinical outcomes of modified transperitoneal laparoscopic radical prostatectomy. Methods A total of 285 patients received the operation with mean age of 67 years (50-76 years) from January 2008 to April 2012.Mean level of PSA was 15.7 μg/L (1.8 -50.0 μg/L),and mean prostatic volume was 44 ml (26 -74 ml). No lymph node or seminal vesicle involvement was found by CT or MR and radionuclide bone scan revealed no metastasis.271 cases were confirmed diagnosis by prostatic biopsy and 14 were detected through pathological studies of TURP specimens.Gleason score ranged from 6 to 8.14 cases were in clinical stage T1b,29 cases in T1c,214 cases in T2 and 28 cases in T3a.Transperitoneal approach and modified technique involving bladder neck dissection,nervesparing technique and vesicoureteral anastomosis were applied on patients. Results Mean operative time was 105 min (55 -150 min).Mean intraoperative estimated blood loss was 240 ml (50-800 ml).Rectal injures occurred in 2 cases and were repaired under laparoscopy.Drainage tube and urinary catheter were removed 48 -72 h and 5 -8 d postoperatively.Postoperative hospital stay was 7 d (5 - 11 d).Positive surgical margin was present in 58 patients.Mean follow-up time was 29 months (3 -50 months).Complete continence were found in 208 patients immediately after catheter removal.68 patient recovered continence within 3 months and 9 patients remained incontinence 3 months after surgery. Normal erection presented in 42 of the 57 cases with nerve-sparing. Conclusions Transperitoneal laparoscopic radical prostatectomy is safe and efficient.Higher efficiency and lower complication rate have been achieved through modified laparoscopic technique involving bladder neck dissection,nerve-sparing technique and vesicoureteral anastomosis. Key words: Prostatic neoplasms; Laparoscopy; Transperitoneal approach; Radical prostatectomy

Editorial Comment to Similar functional outcomes after partial nephrectomy for clinical T1b and T1a renal cell carcinoma

Editorial Comment to Similar functional outcomes after partial nephrectomy for clinical T1b and T1a renal cell carcinoma

Similar functional outcomes after partial nephrectomy for clinical T1b and T1a renal cell carcinoma

To examine the medium-term functional outcomes of partial nephrectomy for clinical T1b renal cell carcinoma, and to compare them with those of radical nephrectomy for clinical T1b and with those of partial nephrectomy for clinical T1a tumors. The participants of this study were patients operated for clinical T1a and clinical T1b tumors operated at Tokyo Women's Medical University, Tokyo, Japan, between January 1979 and June 2011. A total of 67 patients underwent partial nephrectomy for clinical T1b tumor, 195 patients underwent radical nephrectomy for clinical T1b tumors and 324 underwent partial nephrectomy for clinical T1a tumors. The outcomes of these three groups were compared. Partial nephrectomy provided better preservation of residual renal function compared with radical nephrectomy for clinical T1b, and the postoperative estimated glomerular filtration rate was similar in the patients who underwent partial nephrectomy for clinical T1b and those who underwent partial nephrectomy for clinical T1a. Postoperative renal function was steadily maintained after partial nephrectomy during the medium-term follow up. The probability of freedom from new onset of chronic kidney disease after partial nephrectomy for clinical T1b tumors was significantly higher from that after radical nephrectomy for clinical T1b tumors, and similar to that after partial nephrectomy for clinical T1a tumors. The higher anatomical complexity of clinical T1b tumors is unlikely to provide a significant influence on postoperative renal function after partial nephrectomy, when compared with the clinical T1a tumors. These findings support the beneficial role of partial nephrectomy in the preservation of renal function of clinical T1b renal cell carcinoma patients undergoing surgery.

Clinical outcome of endoscopic mucosal resection for esophageal squamous cell cancer invading muscularis mucosa and submucosal layer

When a tumor invades the muscularis mucosa and submucosal layer (T1a-MM and T1b in Japan), esophageal squamous cell cancer poses 10-50% risk of lymph node metastasis. By this stage of esophageal cancer, surgery, although very invasive, is the standard radical therapy for the patients. Endoscopic mucosal resection (EMR) is the absolutely curable treatment for cancer in the superficial mucosal layer. Because of its minimal invasiveness, the indications of EMR may be expanded to include the treatment of T1a-MM and T1b esophageal carcinoma. To date, the clinical outcomes of EMR for T1a-MM and T1b patients have not been fully elucidated. Here, the retrospective analysis of the clinical outcomes is reported. Between January 1994 and December 2007, 247 patients underwent EMR at Kanagawa Cancer Center. Of these individuals, 44 patients with 44 lesions fulfilled the following criteria: (i) extended EMR treatment for clinical T1a-MM and T1b tumor; (ii) diagnosis of clinical N0M0; and (iii) follow up for at least 1 year, and negative vertical margin. These patients were reviewed for their clinical features and outcomes. Statistical analyses were performed by the Kaplan-Meier methods, the Chi-square test, and the Cox proportional hazard model. P-value of <0.05 was considered statistically significant. The data were analyzed in February 2009. Based on the informed consent and their general health conditions, 44 patients decided the following treatments immediately after the EMR: 2 underwent surgery, 1 underwent adjuvant chemotherapy, and 41 selected follow up without any additional therapy. Of the 41 patients, 20 selected this course by choice, 12 because of severe concurrent diseases, 2 because of poor performance status, and 7 because of other multiple primary cancers. Twelve patients died; two were cause specific (4.5%), eight from multiple primary cancers, one from severe concurrent diseases, and one from unknown causes. No critical complications were noted. Median follow-up time was 51 months (12-126). Five patients ultimately developed lymph node metastasis. One patient with adjuvant chemotherapy required surgery, and another was treated with chemotherapy whose subsequent death was cause specific. The other three patients received chemoradiotherapy and have not shown cause-specific death. Overall and cause-specific survival rates at 5 years were 67.3% and 91.8%, respectively. Among 41 patients treated by EMR alone, only one died from primary esophageal cancer (2.4%), and overall and cause-specific survival rates at 5 years were 75.6% and 97.6%, respectively. Multivariate analysis revealed that severe concurrent diseases including multiple primary cancers and the administration of 5-fluorouracil-based chemotherapy for multiple primary cancers significantly influenced survival (P= 0.025, hazard ratio [HR] 13.1 [95% confidence interval 1.5-114]) and (P= 0.037, HR 0.213 [95% confidence interval 0.05-0.914]), respectively. Eight and six patients developed metachronous esophageal squamous cell cancer and local recurrence, respectively. With the exception of one patient, they could be retreated endoscopically. EMR is a reasonable option for the patients with T1a-MM and T1b esophageal carcinoma without clinical metastasis, especially for the individuals with severe concurrent diseases. The prognostic factors for the benefit of EMR in such cases should be further examined.

Comparative Effectiveness for Survival and Renal Function of Partial and Radical Nephrectomy for Localized Renal Tumors: A Systematic Review and Meta-Analysis

The relative effectiveness of partial vs radical nephrectomy remains unclear in light of the recent phase 3 European Organization for the Research and Treatment of Cancer trial. We performed a systematic review and meta-analysis of partial vs radical nephrectomy for localized renal tumors, considering all cause and cancer specific mortality, and severe chronic kidney disease. Cochrane Central Register of Controlled Trials, MEDLINE®, EMBASE®, Scopus and Web of Science® were searched for sporadic renal tumors that were surgically treated with partial or radical nephrectomy. Generic inverse variance with fixed effects models were used to determine the pooled HR for each outcome. Data from 21, 21 and 9 studies were pooled for all cause and cancer specific mortality, and severe chronic kidney disease, respectively. Overall 31,729 (77%) and 9,281 patients (23%) underwent radical and partial nephrectomy, respectively. According to pooled estimates partial nephrectomy correlated with a 19% risk reduction in all cause mortality (HR 0.81, p < 0.0001), a 29% risk reduction in cancer specific mortality (HR 0.71, p = 0.0002) and a 61% risk reduction in severe chronic kidney disease (HR 0.39, p < 0.0001). However, the pooled estimate of cancer specific mortality for partial nephrectomy was limited by the lack of robustness in consistent findings on sensitivity and subgroup analyses. Our findings suggest that partial nephrectomy confers a survival advantage and a lower risk of severe chronic kidney disease after surgery for localized renal tumors. However, the results should be evaluated in the context of the low quality of the existing evidence and the significant heterogeneity across studies. Future research should use higher quality evidence to clearly demonstrate that partial nephrectomy confers superior survival and renal function.

Long-Term Outcomes of Renal Tumor Radio Frequency Ablation Stratified by Tumor Diameter: Size Matters

Renal tumor size influences the efficacy of radio frequency ablation but identification of confident size cutoffs has been limited by small numbers and short followup. We evaluated tumor size related outcomes after radio frequency ablation for patients with adequate (greater than 3 years) followup. We identified 159 tumors treated with radio frequency ablation as primary treatment. Disease-free survival was defined as the time from definitive treatment to local recurrence, detection of metastasis or the most recent imaging showing no evidence of disease. Patients were evaluated with contrast enhancing imaging preoperatively, and at 6 weeks, 6 months and at least annually thereafter. Median tumor size was 2.4 cm (range 0.9 to 5.4) with a median followup of 54 months (range 1.5 to 120). Renal cell carcinoma was confirmed in 72% of the 150 tumors that had pre-ablation biopsy (94%). The 3 and 5-year disease-free survival was comparable at 92% and 91% overall, and was dependent on tumor size, being 96% and 95% for tumors smaller than 3.0 cm and 79% and 79%, respectively, for tumors 3 cm or larger (p=0.001). Most failures (14 of 18) were local, either incomplete ablations or local recurrences. This is an intent to treat analysis and, therefore, includes patients ultimately found to have benign tumors, although outcomes were comparable in patients with cancer. Radio frequency ablation treatment success of the small renal mass is strongly correlated with tumor size. Radio frequency ablation provides excellent and durable outcomes, particularly in tumors smaller than 3 cm. Of tumors 3 cm or larger, approximately 20% will recur such that alternative treatment techniques should be considered. However, most treatment failures are local and are often successfully treated with another ablation session.

Argon plasma coagulation for superficial esophageal squamous-cell carcinoma in high-risk patients

To evaluate the usefulness and safety of argon plasma coagulation (APC) for superficial esophageal squamous-cell carcinoma (SESC) in high-risk patients. We studied 17 patients (15 men and 2 women, 21 lesions) with SESC in whom endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and open surgery were contraindicated from March 1999 through February 2009. None of the patients could tolerate prolonged EMR/ESD or open surgery because of severe concomitant disease (e.g., liver cirrhosis, cerebral infarction, or ischemic heart disease) or scar formation after EMR/ESD and chemoradiotherapy. After conventional endoscopy, an iodine stain was sprayed on the esophageal mucosa to determine the lesion margins. The lesion was then ablated by APC. We retrospectively studied the treatment time, number of APC sessions per site, complications, presence or absence of recurrence, and time to recurrence. The median duration of follow-up was 36 mo (range: 6-120 mo). All of the tumors were macroscopically classified as superficial and slightly depressed type (0-IIc). The preoperative depth of invasion was clinical T1a (mucosal cancer) for 19 lesions and clinical T1b (submucosal cancer) for 2. The median treatment time was 15 min (range: 10-36 min). The median number of treatment sessions per site was 2 (range: 1-4). The median hospital stay was 14 d (range: 5-68 d). Among the 17 patients (21 lesions), 2 (9.5%) had recurrence and underwent additional APC with no subsequent evidence of recurrence. There were no treatment-related complications, such as bleeding or perforation. APC is considered to be safe and effective for the management of SESC that cannot be resected endoscopically because of underlying disease, as well as for the control of recurrence after EMR and local recurrence after chemoradiotherapy.

POD-06.06 Multi-Institutional Analysis of Robotic Assisted Partial Nephrectomy for Clinical Stage T1b Renal Tumors: Perioperative Outcomes in 445 Patients

POD-06.06 Multi-Institutional Analysis of Robotic Assisted Partial Nephrectomy for Clinical Stage T1b Renal Tumors: Perioperative Outcomes in 445 Patients

A Multidisciplinary Evaluation of Inter-Reviewer Agreement of the Nephrometry Score and the Prediction of Long-Term Outcomes

The nephrometry score was introduced in 2009 as a way to quantify renal tumor complexity in a systematic way. However, the reproducibility of scoring has not been rigorously validated across specialty or level of training, nor has it been evaluated with regard to meaningful clinical outcomes. We identified 95 consecutive patients with a solid renal mass treated surgically. Each renal tumor was separately scored by 6 reviewers, including 2 staff urologists, 1 staff radiologist, 2 trainees (1 urology, 1 radiology) and 1 medical student. Inter-reviewer agreement for nephrometry score was evaluated using Lin's concordance correlation coefficient. We evaluated the ability of the nephrometry score to predict surgery type, pathological features and clinical outcomes. Agreement in nephrometry score was substantial among the 3 staff physicians (0.72, 95% CI 0.64-0.80). Nephrometry score agreement continued to be substantial when including the trainees and medical student in the analysis (0.75, 95% CI 0.69-0.81). The median nephrometry score of patients treated with radical nephrectomy was 9.0 vs 7.2 for those treated with a nephron sparing approach (p <0.001). Increasing nephrometry score was associated with increased risk of distant metastasis (HR 3.27, p <0.001), death from renal cell carcinoma (HR 2.83, p <0.001) and death from any cause (HR 1.24, p = 0.017). Nephrometry scoring with minimal initial instruction was robust across specialties and levels of training. The additional anatomical information that nephrometry score adds to size alone may be associated with other important clinical outcomes such as tumor aggressiveness and survival, and warrants further study.

Impact of Tumor Size on Renal Function and Prediction of Renal Insufficiency After Radical Nephrectomy in Patients With Renal Cell Carcinoma

From the perspective of oncological and functional outcomes partial nephrectomy is considered standard surgery for small renal tumors 4 cm or less. However, radical nephrectomy is commonly done for small tumors. It is important to predict postoperative renal function in patients to choose the most optimal surgical procedure. We retrospectively reviewed the records of 271 patients treated with radical nephrectomy for renal cell carcinoma. Associations of tumor size and clinical variables with renal function were analyzed. Preoperatively the mean ± SD glomerular filtration rate was 74.38 ± 17.70 ml per minute/1.73 m(2) and 56 patients (20%) had renal insufficiency (glomerular filtration rate less than 60 ml per minute/1.73 m(2)). The mean decrease in the glomerular filtration rate after radical nephrectomy was 24.2 ± 12.40 ml per minute/1.73 m(2) (31.5% ± 15%). Of 215 patients with a preoperative glomerular filtration rate of 60 ml per minute/1.73 m(2) or greater 165 (77%) had new onset renal insufficiency. Age, tumor size, preoperative glomerular filtration rate and hypertension were significantly associated with new onset renal insufficiency. Multivariate analysis revealed that age 60 years or greater, tumor size 7 cm or less and the preoperative glomerular filtration rate were independent risk factors for new onset renal insufficiency (p <0.05). Finally, we developed a predictive model for new onset renal insufficiency after radical nephrectomy. Tumor size 7 cm or less, age 60 years or greater and a decreased preoperative glomerular filtration rate were significant risk factors for new onset renal insufficiency in patients treated with radical nephrectomy. Partial nephrectomy might be considered an option according to the risk of postoperative renal insufficiency, especially in elderly patients with a tumor of 7 cm or less.