Surgery For Kidney Cancer Research Articles

Open versus mini-invasive partial and radical nephrectomy complications: results from the French national health database

BackgroundLaparoscopic surgery is associated with a lower morbidity than open surgery. No recent data compared kidney cancer surgery in the French population using the National Health Insurance database (PMSI-MCO).AimsWe explore and compare the surgical morbidity rates between laparoscopic and open laparotomy for kidney cancer.MethodsThe initial length of stay and complications parameters during the three postoperative months were described for renal cancer in every French center in 2018. We compared Relative Risks (RR [95% CI]) between laparoscopic and open surgery for both radical and partial nephrectomy.ResultsAmong 8,162 patients, 3,525 had a radical nephrectomy, 978 open, 2,547 laparoscopic surgeries; 4,637 patients had partial nephrectomies, 1,778 open 2,859 laparoscopic surgeries. For radical surgery, the most common complications were urinary infections (7.8%), acute renal failure (8.9%), sepsis (8.4%), bleeding (9.3%), and postoperative anemia (5.9%); the RR for laparoscopic versus open surgery were respectively 0.68 [0.54;0.86], 0.71 [0.57;0.88], 0.69 [0.55;0.86], 0.83 [0.66;1.03], 0.56 [0.43;0.73]. For partial nephrectomies, the most common complications were urinary infections (7.7%), bleeding (11.6%), and postoperative anemia (5.8%), with RR of 0.71 [0.58;0.87], 0.61 [0.52;0.71], and 0.64 [0.51;0.81]. The mean length of stay was 7.7 for open radical nephrectomy, 6.3 for laparoscopic radical nephrectomy, 7.5 for open partial nephrectomy, and 5 for laparoscopic partial nephrectomy.ConclusionsThe laparoscopic approach had fewer postoperative complications and a shorter length of stay than open surgery for partial and radical nephrectomy. The PMSI analysis provided an exhaustive description of surgical practice for kidney cancer and surgical complications in France.Clinical trial numberNot applicable.

Metaverse in surgery - origins and future potential.

The metaverse refers to a collective virtual space that combines physical and digital realities to create immersive, interactive environments. This space is powered by technologies such as augmented reality (AR), virtual reality (VR), artificial intelligence (AI) and blockchain. In healthcare, the metaverse can offer many applications. Specifically in surgery, potential uses of the metaverse include the possibility of conducting immersive surgical training in a VR or AR setting, and enhancing surgical planning through the adoption of three-dimensional virtual models and simulated procedures. At the intraoperative level, AR-guided surgery can assist the surgeon in real time to increase surgical precision in tumour identification and selective management of vessels. In post-operative care, potential uses of the metaverse include recovery monitoring and patient education. In urology, AR and VR have been widely explored in the past decade, mainly for surgical navigation in prostate and kidney cancer surgery, whereas only anecdotal metaverse experiences have been reported to date, specifically in partial nephrectomy. In the future, further integration of AI will improve the metaverse experience, potentially increasing the possibility of carrying out surgical navigation, data collection and virtual trials within the metaverse. However, challenges concerning data security and regulatory compliance must be addressed before the metaverse can be used to improve patient care.

Teaching Hospitals and Textbook Outcomes After Major Urologic Cancer Surgery

ObjectivesTo assess textbook outcomes by hospital teaching status follow major surgery for genitourinary malignancies. MethodsWe used 100% national Medicare Provider Analysis and Review files from 2017-2020 to assess rates of textbook outcomes in undergoing bladder (i.e., radical cystectomy), kidney (i.e., radical or partial nephrectomy), and prostate (i.e., radical prostatectomy) surgery for genitourinary malignancies. The extent of integration of learners into each hospital’s workforce—defined as major, minor and non- teaching—was the primary exposure. A textbook outcome, measured at the patient level, was defined as the absence of in-hospital mortality and mortality within 30 days of surgery, no readmission 30 days following discharge, no postoperative complication, and no prolonged length of stay. ResultsTextbook outcomes were achieved in 51% (8,564/16,786) of patients after bladder cancer surgery, 70% (39,938/57,300) of patients after kidney cancer surgery, and 82% (50,408/61,385) of patients after prostate cancer surgery. After adjusting for patient- and hospital-level characteristics, teaching hospitals had higher rates of textbook outcomes in those undergoing bladder (50.7% vs 44.0%; p = 0.001), kidney (72.0% vs 69.7%; p = 0.02), and prostate (85.3% vs 81.0%; p < 0.001) surgery. This effect was attenuated, but not eliminated, by surgical volume in additional sensitivity analyses for bladder (OR: 1.20, 95% CI: 1.00 -1.42; p = 0.04) and prostate (OR: 1.15, 95% CI: 1.00-1.32; p = 0.04) surgery. There were no significant differences in kidney cancer surgery outcomes after adjusting for hospital volume (OR: 1.03, 95% CI: 0.93 – 1.14; p = 0.6). ConclusionsUndergoing major cancer surgery at a teaching hospital was associated with an increased likelihood of receiving a textbook outcome. This effect was attenuated by volume but persisted for bladder and prostate surgery.

#2171 The impact of preoperative hypertension and blood pressure control on kidney outcomes after surgery for localized kidney cancer: a prospective study

Abstract Background and Aims Kidney surgery represents the treatment of choice for localized renal cell carcinomas (RCC). Postoperative acute kidney injury (AKI) is reported in 40% of the patients undergoing partial nephrectomy [1]. A nephron-sparing approach is not always feasible for anatomical as well as oncological reasons and total nephrectomy is associated with an even higher risk of both acute and chronic impairment of renal function. Recently, interest has risen in the development of prediction models able to preoperatively identify patients at higher risk of AKI and chronic kidney disease (CKD) development after kidney surgery, but the role of hypertension in this field is yet underexplored. The aim of the present study was therefore to assess the impact of hypertension and blood pressure control on kidney outcomes after surgery for RCC. Method We prospectively enrolled 45 patients with an estimated glomerular-filtration-rate (eGFR) &amp;gt; 45 ml/min per 1.73 m2 who underwent kidney surgery for RCC at our institution between May 1, 2022, and September 30, 2023. Clinical characteristics of the study cohort are reported in Table 1. In-hospital AKI was defined as an increase of serum creatinine &amp;gt; 0.3 mg/dl from baseline and CKD development (defined as eGFR &amp;lt;60 ml/min/1.73 m2) was evaluated at 3 months. Ambulatory blood pressure monitoring (24h-ABPM) was assessed at baseline. Comparisons between groups were made by analysis of variance. Comparisons of proportions among groups were made using the χ2 test. Multivariate logistic regression analysis was used to describe the relationship between clinical variables and the presence of in-hospital AKI. Results Among the 45 patients enrolled, 42% (n = 19) developed postoperative AKI, of whom 32% (n = 6) had a complete kidney function recovery, whereas 68% (n = 13) developed CKD. Of the 39 patients with a basal ABPM evaluation, 87% (n = 34) had a diagnosis of hypertension. For 35% (n = 12) of these patients a first diagnosis of hypertension was made. AKI patients had higher median SBP (143 ± 9 vs 133 ± 12 mmHg, p = 0.008) and SBP variability (24 ± 4 vs 20 ± 5 mmHg, p = 0.01) compared with non-AKI patients. Preoperative 24h-SBP &amp;gt;130 mmHg was independently associated with in-hospital AKI (p = 0.05), regardless of age, gender, hypertension, diabetes and antihypertensive treatment. Considering the 3-month eGFR, we observed that compared with non-AKI patients, baseline 24h-SBP was higher, as a trend, in AKI patients who did not develop CKD or in those developing CKD on previous normal kidney function (de novo CKD), while no difference in 24h-SBP was observed between AKI and non-AKI patients in the subgroup of patients with preoperative CKD (CKD on CKD) (Fig. 1). Conclusion Preoperative hypertension, a potentially modifiable risk factor, is associated with an increased risk of AKI after kidney surgery. Moreover, an early identification of hypertension is of utmost importance taking into account that a strict blood pressure control, regardless of renal function at baseline, may be crucial to counteract the development or the progression of CKD.

Trends and Costs of Minimally Invasive Surgery for Kidney Cancer in the US: A Population-based Study

ObjectiveTo analyze temporal trends and costs associated with the use of minimally invasive surgery (MIS) for kidney cancer in the US over the past decade. To examine the impact of social determinants of health (SDOH) on perioperative outcomes. MethodsThe PearlDiver Mariner, a national database of insurance billing records, was queried for this retrospective observational cohort analysis. The MIS population was identified and stratified according to treatment modality, using International Classification of Diseases (ICD) and current procedural terminology (CPT) codes. SDOH were assessed using ICD codes. Negative binomial regression was used to evaluate the overall number of renal MIS and Cochran-Armitage tests to compare the utilization of different treatment modalities, over the study period. Multivariable logistic regression analysis identified predictors of perioperative complications. ResultsA total of 80,821 MIS for kidney cancer were included. Minimally invasive partial nephrectomy (MIPN) adoption as a fraction of total MIS increased significantly (slope of regression line, reg. = 0.026, p<.001). Minimally invasive radical nephrectomy (MIRN) ($26,9k±40,9k) and renal ablation (RA) ($18,9k±31,6k) were the most expensive and the cheapest procedure, respectively. No statistically significant difference was observed in terms of number of complications (p=.06) and presence of SDOH (p=.07) among the treatment groups. At multivariable analysis, patients with SDOH undergoing MIRN had higher odds of perioperative complications, while RA had a significantly lower probability of perioperative complications. ConclusionsThis study describes the current management of kidney cancer in the US, offering a socioeconomic perspective on the impact of this disease in everyday clinical practice. Data AvailabilityRaw data generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Could a Risk-adapted Approach Support Shared Decision-making Regarding Eligibility for Adjuvant Pembrolizumab for Patients with Clear Cell Renal Cell Carcinoma at High Risk of Recurrence? A Multicentre Cohort Study

The KEYNOTE-564 randomised controlled trial showed a disease-free survival benefit of adjuvant pembrolizumab (aPZB) in comparison to placebo for patients with clear cell renal cell carcinoma (ccRCC) at high risk of recurrence. Despite its recommendation by the European Association of Urology guidelines, the ultimate value of aPZB has recently been questioned. Arguably, patients who might benefit the most from aPZB are those whose probability of RCC recurrence outweighs their probability of dying from other causes over a reasonable timeframe after surgery. To assess the potential impact of this hypothesis on “eligibility” for aPZB, we queried our prospectively collected multi-institutional database for consecutive patients undergoing surgery for nonmetastatic renal masses (cT1–4 N0–1 M0) between 2015 and 2021 to identify ccRCC cases meeting the KEYNOTE-564 criteria. We stratified the patients using the risk-adapted model proposed by Stewart-Merrill et al (whereby stopping follow-up is warranted when the estimated risk of other-cause mortality [OCM] outweighs the estimated risk of RCC recurrence). Then we explored the proportion of patients whose follow-up could theoretically be stopped at 2, 5, 10, or 20 yr, for whom “eligibility” for aPZB might be more controversial. Overall, 1745 patients with ccRCC were included, of whom 419 (24%) met the KEYNOTE-564 criteria. The proportion of patients “not eligible” for aPZB because of higher probability of OCM than of RCC recurrence would have been 81%, 66%, 43%, and 29% at “recommended” follow-up of ≤2.0, ≤5, ≤10, and ≤20 yr, respectively. To the best of our knowledge, this is the first study providing insights to support shared decision-making regarding eligibility for aPZB for patients with nonmetastatic ccRCC with a focus on patient-related factors beyond tumour-driven prognostic scores. Patient summaryAn immunotherapy drug call pembrolizumab given after surgery for nonmetastatic kidney cancer may benefit some patients who have a high risk of disease recurrence, but it can have immune-related side effects. We found that comparing the risk of death from other causes and the risk of cancer recurrence could help in reducing overtreatment of patients who might not benefit from this drug.

The association of marital status with kidney cancer surgery morbidity - a retrospective cohort study.

To better understand whether the marital status impacts 90-day postoperative outcomes following kidney cancer surgery. We performed a retrospective cohort study of adult patients undergoing elective partial or radical nephrectomy to manage kidney masses from 2003 to 2017 using the Premier Hospital Database, a national hospital discharge dataset. Multinomial logistic regression models controlling for a wide range of clinicodemographic, surgical, and hospital characteristics were used to assess an association between marital status and postoperative complications. The primary outcome was 90-day complications, including minor complications (Clavien grades 1-2), non-fatal major complications (Clavien grades 3-4), and mortality (Clavien grade 5). Secondary outcomes included patient disposition and readmission rates. The study cohort comprised 106,752 patients, of which 61,188 (57.32%) were married. The overall incidence of minor complications, major complications, and death was 24.04%, 6.00%, and 0.71%, respectively. Marriage was associated with a significantly lower incidence of minor (RR 0.97; 95% CI: 0.94-0.99) complications following open or radical nephrectomy and major complications (RR 0.89; 95% CI: 0.84-0.95) for all surgical types and approaches. There was no association between marital status and mortality (RR 0.94; 95% CI: 0.81-1.10). Marriage is associated with a significant reduction in major complications following kidney cancer surgery, likely because it is associated with greater social support, which is beneficial in the postoperative phase of care. Marital status and social support may play a role in the preoperative decision-making process and counseling for patients considering kidney cancer surgery.

Artificial Intelligence in Surgical Training for Kidney Cancer: A Systematic Review of the Literature.

The prevalence of renal cell carcinoma (RCC) is increasing due to advanced imaging techniques. Surgical resection is the standard treatment, involving complex radical and partial nephrectomy procedures that demand extensive training and planning. Furthermore, artificial intelligence (AI) can potentially aid the training process in the field of kidney cancer. This review explores how artificial intelligence (AI) can create a framework for kidney cancer surgery to address training difficulties. Following PRISMA 2020 criteria, an exhaustive search of PubMed and SCOPUS databases was conducted without any filters or restrictions. Inclusion criteria encompassed original English articles focusing on AI's role in kidney cancer surgical training. On the other hand, all non-original articles and articles published in any language other than English were excluded. Two independent reviewers assessed the articles, with a third party settling any disagreement. Study specifics, AI tools, methodologies, endpoints, and outcomes were extracted by the same authors. The Oxford Center for Evidence-Based Medicine's evidence levels were employed to assess the studies. Out of 468 identified records, 14 eligible studies were selected. Potential AI applications in kidney cancer surgical training include analyzing surgical workflow, annotating instruments, identifying tissues, and 3D reconstruction. AI is capable of appraising surgical skills, including the identification of procedural steps and instrument tracking. While AI and augmented reality (AR) enhance training, challenges persist in real-time tracking and registration. The utilization of AI-driven 3D reconstruction proves beneficial for intraoperative guidance and preoperative preparation. Artificial intelligence (AI) shows potential for advancing surgical training by providing unbiased evaluations, personalized feedback, and enhanced learning processes. Yet challenges such as consistent metric measurement, ethical concerns, and data privacy must be addressed. The integration of AI into kidney cancer surgical training offers solutions to training difficulties and a boost to surgical education. However, to fully harness its potential, additional studies are imperative.

Nephrectomy for kidney tumor increases the risk of de novo arterial hypertension.

Kidney is an essential regulator of arterial blood pressure (BP) via the renin-angiotensin system. The impact of kidney surgery on BP is unclear. To evaluate the consequences of kidney surgery for renal tumor on BP. In a multicenter prospective study, we evaluated 200 patients who underwent nephrectomy for renal tumor between 2018 and 2020 at 7 departments of the UROCCR network. All patients had localized cancer without pre-existing hypertension. BP was measured the week before nephrectomy, one month and six months after nephrectomy, according to the recommendations for home blood pressure measurement. Plasmatic renin was measured one week before surgery and 6 months after surgery. The primary endpoint was the occurrence of de novo hypertension (HTN). The secondary endpoint was a clinically significant increase in BP at six months defined by an increase in systolic and / or diastolic ABP ≥10 mmHg or if medical anti-hypertensive treatment was required RESULTS AND LIMITATIONS: BP and renin measurements were available for 182 (91%) and 136 (68%) patients, respectively. We excluded from the analysis 18 patients who had undeclared HTN detected on preoperative measurements. At six months, 31 (19.2%) patients had de novo HTN and 43 (26.3%) patients had a significant increase in their BP. The type of surgery was not associated with an increased risk of HTN (21.7% PN vs 15.7% RN; p=0.59). There was no difference between plasmatic renin levels before and after surgery (18.5 vs. 16, p=0.46). In multivariable analysis, age (O.R 1.07; CI-95 1.02-1.12; p=0.03) and BMI (O.R. 1.14; CI-95 1.03-1.26; p=0.01) were the only predictors of de novo HTN. Surgical treatment of renal tumors is associated with significant changes in BP. These changes are not impacted by the type of surgery (PN vs RN). In this study we evaluated blood pressure changes after surgery for renal tumors. We found that 19% of the patients developed de novo hypertension 6 months after surgery. We feel that patients who are scheduled to undergo kidney cancer surgery should be informed of these findings and have their blood pressure closely monitored after the operation.

A Predictive Model for Kidney Failure After Nephrectomy for Localized Kidney Cancer: The Kidney Cancer Risk Equation

Nephrectomy is the mainstay of treatment for individuals with localized kidney cancer. However, surgery can potentially result in the loss of kidney function or in kidney failure requiring dialysis/kidney transplantation. There are currently no clinical tools available to preoperatively identify which patients are at risk of kidney failure over the long term. Our study developed and validated a prediction equation for kidney failure after nephrectomy for localized kidney cancer. Population-level cohort study. Adults (n=1,026) from Manitoba, Canada, with non-metastatic kidney cancer diagnosed between January 1, 2004, and December 31, 2016, who were treated with either a partial or radical nephrectomy and had at least 1 estimated glomerular filtration rate (eGFR) measurement before and after nephrectomy. A validation cohort included individuals in Ontario (n=12,043) with a diagnosis of localized kidney cancer between October 1, 2008, and September 30, 2018, who received a partial or radical nephrectomy and had at least 1 eGFR measurement before and after surgery. Age, sex, eGFR, urinary albumin-creatinine ratio, history of diabetes mellitus, and nephrectomy type (partial/radical). The primary outcome was a composite of dialysis, transplantation, or an eGFR<15mL/min/1.73m2 during the follow-up period. Cox proportional hazards regression models evaluated for accuracy using area under the receiver operating characteristic curve (AUC), Brier scores, calibration plots, and continuous net reclassification improvement. We also implemented decision curve analysis. Models developed in the Manitoba cohort were validated in the Ontario cohort. In the development cohort, 10.3% reached kidney failure after nephrectomy. The final model resulted in a 5-year area under thecurve of 0.85 (95% CI, 0.78-0.92) in the development cohort and 0.86 (95% CI, 0.84-0.88) in the validation cohort. Further external validation needed in diverse cohorts. Our externally validated model can be easily applied in clinical practice to inform preoperative discussions about kidney failure risk in patients facing surgical options for localized kidney cancer. Patients with localized kidney cancer often experience a lot of worry about whether their kidney function will remain stable or will decline if they choose to undergo surgery for treatment. To help patients make an informed treatment decision, we developed a simple equation that incorporates 6 easily accessible pieces of patient information to predict the risk of reaching kidney failure 5 years after kidney cancer surgery. We expect that this tool has the potential to inform patient-centered discussions tailored around individualized risk, helping ensure that patients receive the most appropriate risk-based care.

Association between Preoperative Psychiatric Morbidities and Mortality after Oncologic Surgery: A Nationwide Cohort Study from 2002 to 2019 in South Korea.

We aimed to examine whether preoperative psychiatric morbidities affect 30-day postoperative mortality. Using a nationwide registration database in South Korea, the study included all patients who underwent curative cancer surgery from 1 January 2002 to 31 December 2019. Patients underwent surgery for breast, laryngeal, lung, thyroid, gastric, colorectal, esophageal, liver, pancreatic, kidney, bladder, testicular, prostate, vulvar, uterine, or brain cancer. Depression, anxiety disorder, substance abuse, and post-traumatic stress disorder were considered preoperative psychiatric morbidities. Among the 944,794 patients in the final analysis, 5490 (0.6%) died within 30 days of the surgery, and 24,370 (2.6%) had preoperative psychiatric morbidities. Multivariable logistic regression analysis showed that preoperative psychiatric morbidities were associated with a higher (adjusted odds ratio [aOR]: 1.23; 95% confidence interval [CI]: 1.09, 1.39; p = 0.001) 30-day mortality rate than the rate noted for patients without preoperative psychiatric morbidities. This association was significant in the breast (aOR: 3.31, 95% CI: 1.36, 8.07; p = 0.009), lung (aOR: 1.54, 95% CI: 1.19, 2.01; p = 0.001), and kidney (aOR: 1.87, 95% CI: 1.06, 3.31; p = 0.03) cancer groups in the subgroup analyses. In South Korea, preoperative psychiatric morbidities are considered to be associated with increased 30-day postoperative mortality.

Kidney Cancer Diagnosis and Surgery Selection by Machine Learning from CT Scans Combined with Clinical Metadata

Kidney cancers are one of the most common malignancies worldwide. Accurate diagnosis is a critical step in the management of kidney cancer patients and is influenced by multiple factors including tumor size or volume, cancer types and stages, etc. For malignant tumors, partial or radical surgery of the kidney might be required, but for clinicians, the basis for making this decision is often unclear. Partial nephrectomy could result in patient death due to cancer if kidney removal was necessary, whereas radical nephrectomy in less severe cases could resign patients to lifelong dialysis or need for future transplantation without sufficient cause. Using machine learning to consider clinical data alongside computed tomography images could potentially help resolve some of these surgical ambiguities, by enabling a more robust classification of kidney cancers and selection of optimal surgical approaches. In this study, we used the publicly available KiTS dataset of contrast-enhanced CT images and corresponding patient metadata to differentiate four major classes of kidney cancer: clear cell (ccRCC), chromophobe (chRCC), papillary (pRCC) renal cell carcinoma, and oncocytoma (ONC). We rationalized these data to overcome the high field of view (FoV), extract tumor regions of interest (ROIs), classify patients using deep machine-learning models, and extract/post-process CT image features for combination with clinical data. Regardless of marked data imbalance, our combined approach achieved a high level of performance (85.66% accuracy, 84.18% precision, 85.66% recall, and 84.92% F1-score). When selecting surgical procedures for malignant tumors (RCC), our method proved even more reliable (90.63% accuracy, 90.83% precision, 90.61% recall, and 90.50% F1-score). Using feature ranking, we confirmed that tumor volume and cancer stage are the most relevant clinical features for predicting surgical procedures. Once fully mature, the approach we propose could be used to assist surgeons in performing nephrectomies by guiding the choices of optimal procedures in individual patients with kidney cancer.

Racial and ethnic disparities in surgery for kidney cancer: a SEER analysis, 2007–2014

ABSTRACT Background and Objectives: Compared with White patients, Black and American Indian/Alaskan Native (AI/AN) patients experience higher rates of kidney cancer incidence, and Black, AI/AN, and Hispanic patients face later stages of disease at diagnosis, poorer survival rates, and greater risk of mortality. Despite the importance that appropriate treatment has in ensuring positive outcomes, little is known about the association between race and ethnicity and receipt of treatment for kidney cancer. Accordingly, the aim of this study was to explore differences in receipt of treatment and patterns of refusal of recommended treatment by race and ethnicity. Design: 96,745 patients ages 45–84 with kidney cancer were identified in the Surveillance, Epidemiology, and End Results (SEER) program between 2007 and 2014. Logistic regression models were used to examine the association of race and ethnicity with treatment and with patient refusal of recommended treatment. Outcomes of interest were (1) receiving any surgical procedure, and (2) refusing recommended surgery. Results: Relative to White patients, Black and AI/AN patients had lower odds of undergoing any surgical procedure (OR = 0.76; 95% CI: 0.72–0.81; p < 0.001, and OR = 0.92; 95% CI: 0.76–1.10; p = 0.36, respectively) after adjusting for gender, age, insurance status, stage at diagnosis, unemployment status, education status, and income as additive effects. Black and AI/AN patients also had higher odds of refusing recommended surgery (OR = 1.93; 95% CI: 1.56–2.39; p < 0.001, and OR = 1.99; 95% CI: 1.05–3.76; p = 0.035, respectively). Hispanic patients had slightly higher odds of undergoing any surgical procedure (OR = 1.10; 95% CI: 1.04–1.17; p = 0.001) and lower odds of refusal (OR = 0.67; 95% CI: 0.50–0.90; p = 0.007, respectively). Conclusions: Compared with White patients, Black patients were less likely to receive potentially life-saving surgery, and both Black and AI/AN patients were more likely to refuse recommended surgery.

Surgeon-level versus hospital-level quality variance in kidney cancer surgery.

To determine whether variance in kidney cancer surgery quality indicators (QIs) is most impacted by surgeon-level or hospital-level factors in order to inform quality improvement initiatives. The ICES and Veterans Affairs (VA) databases were queried for patients undergoing surgery for localized kidney cancer. Kidney cancer surgery QIs were defined within each cohort. Quality of care was benchmarked at a surgeon- vs. hospital-level to identify statistical outliers, using available clinicopathological data to adjust for differences in case-mix. Variance between surgeons and hospitals was calculated for each QI using a random-effects model. The QI with the greatest amount of variance explained by hospital and surgeon-level factors was proportion of cases performed with minimally invasive surgery (MIS). The majority of this variance was due to surgeon-level factors for both the VA and ICES cohorts. The proportion of cases performed using an MIS approach was also the QI with the greatest number of outlier hospitals and surgeons compared to the average performance. The proportion of partial nephrectomies performed for patients at risk of chronic kidney disease was the QI with the greatest amount of variance due to hospital-level factors for the ICES cohort. The proportion of localized kidney cancer cases performed using an MIS approach is the QI requiring the greatest attention. Quality improvement initiatives should focus on surgeon-level factors to increase the number of MIS cases being performed for patients with localized renal masses.

Role of lymphadenectomy during primary surgery for kidney cancer.

Lymph node dissection (LND) during radical nephrectomy (RN) for renal cell carcinoma (RCC) is not considered as a standard. The emergence of robot-assisted surgery and effective immune checkpoint inhibitors (ICI) in recent years may change this and lymph node (LN) staging has become easier and has a clinical impact. In this review, we aimed to reconsider the role of LND today. Although the extent of LND has still not been well established, removal of more LN seems to provide better oncologic outcomes for a select group of patients with high-risk factors such as clinical T3-4. Adjuvant therapy using pembrolizumab has been shown to improve disease free survival if complete resection of metastatic lesions as well as the primary site is obtained in combination. Robot assisted RN for localized RCC has been widespread and the studies regarding LND for RCC has been recently appeared. The staging and surgical benefits and its extent of LND during RN for RCC remains unclear, but it is becoming increasingly important. Technologies that allow an easier LND and adjuvant ICI that improve survival in LN-positive patients are engaging the role of LND, a procedure that was needed, but almost never done, is now indicated sometimes. Now, the goal is to identify the clinical and molecular imaging tools that can help identify with sufficient accuracy who needs a LND and which LNs to remove in a targeted personalized approach.

MP58-15 LAWTON INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE IDENTIFIES PATIENTS AT HIGH-RISK OF ADVERSE OUTCOMES AFTER KIDNEY SURGERY FOR RENAL CANCER: A PROSPECTIVE CLINICAL STUDY

You have accessJournal of UrologyCME1 Apr 2023MP58-15 LAWTON INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE IDENTIFIES PATIENTS AT HIGH-RISK OF ADVERSE OUTCOMES AFTER KIDNEY SURGERY FOR RENAL CANCER: A PROSPECTIVE CLINICAL STUDY Giuseppe Rosiello, Gianfranco Baiamonte, Giuseppe Basile, Giuseppe Fallara, Chiara Re, Giacomo Musso, Francesco Cei, Daniele Cignoli, Giulio Avesani, Natasha Disabato, Giulia Villa, Mattia Boarin, Daniela Canibus, Pierre I. Karakiewicz, Federico Dehò, Nazareno Suardi, Alberto Briganti, Andrea Salonia, Francesco Montorsi, Alessandro Larcher, and Umberto Capitanio Giuseppe RosielloGiuseppe Rosiello More articles by this author , Gianfranco BaiamonteGianfranco Baiamonte More articles by this author , Giuseppe BasileGiuseppe Basile More articles by this author , Giuseppe FallaraGiuseppe Fallara More articles by this author , Chiara ReChiara Re More articles by this author , Giacomo MussoGiacomo Musso More articles by this author , Francesco CeiFrancesco Cei More articles by this author , Daniele CignoliDaniele Cignoli More articles by this author , Giulio AvesaniGiulio Avesani More articles by this author , Natasha DisabatoNatasha Disabato More articles by this author , Giulia VillaGiulia Villa More articles by this author , Mattia BoarinMattia Boarin More articles by this author , Daniela CanibusDaniela Canibus More articles by this author , Pierre I. KarakiewiczPierre I. Karakiewicz More articles by this author , Federico DehòFederico Dehò More articles by this author , Nazareno SuardiNazareno Suardi More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Andrea SaloniaAndrea Salonia More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Alessandro LarcherAlessandro Larcher More articles by this author , and Umberto CapitanioUmberto Capitanio More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003311.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Frailty is a clinical syndrome associated with delayed recovery and suboptimal outcomes after surgery. Frailty scales have been suggested for identifying frailty before kidney cancer surgery. In this prospective clinical study, we aimed at assessing the role of Lawton Instrumental Activities of Daily Living (IADL) scale in predicting surgical outcomes in patients undergoing partial or radical nephrectomy for renal cell carcinoma (RCC). METHODS: Between January 2021 and June 2022, 98 consecutive patients surgically treated for cT1-2 RCC were prospectively enrolled. The IADL scale was calculated for each patient at hospital admission. Postoperative complications were prospectively collected using Clavien-Dindo classification. Acute kidney injury (AKI) was defined according to the RIFLE criteria. Multivariable logistic and linear regression models tested the association between iADL score and postoperative complications, as well as length of stay (LOS) and postoperative AKI, after adjusting for age, preoperative eGFR, blood loss and tumor characteristics. RESULTS: Overall, 98 patients were included. Of these, 21 (21%) had IADL <6. Median age at surgery and clinical size were 62 [Interquartile range (IQR): 53-71] years and 5 (IQR: 3.4-7) cm. Median preoperative eGFR was 70 (IQR: 56-91) mL/min. Finally, median LOS was 5 (IQR: 4-7) days. Overall, the rate of postoperative complications was 13% (5% of major complications defined as Clavien-Dindo >3). Overall, 22 (22%) out of 98 patients experienced postoperative AKI. At MVA, increasing IADL score predicted lower risk of overall complications [Odds ratio (OR): 0.35, 95%CI 0.22-0.48; p<0.001] and shorter LOS (Relative risk: 0.28, 95%CI 0.19-0.41; p<0.001). Moreover, increasing IADL was independently associated with lower risk of postoperative AKI after surgery (OR: 0.64, 95%CI 0.47-0.88; p<0.01). CONCLUSIONS: Assessing preoperative IADL score allows the identification of patients at increased risk of suboptimal outcomes after surgery for kidney cancer. Therefore, frailty assessment allows the stratification of surgical risks and, potentially, the implementation of dedicated management which may help in protecting frail patients from suboptimal outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e801 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Giuseppe Rosiello More articles by this author Gianfranco Baiamonte More articles by this author Giuseppe Basile More articles by this author Giuseppe Fallara More articles by this author Chiara Re More articles by this author Giacomo Musso More articles by this author Francesco Cei More articles by this author Daniele Cignoli More articles by this author Giulio Avesani More articles by this author Natasha Disabato More articles by this author Giulia Villa More articles by this author Mattia Boarin More articles by this author Daniela Canibus More articles by this author Pierre I. Karakiewicz More articles by this author Federico Dehò More articles by this author Nazareno Suardi More articles by this author Alberto Briganti More articles by this author Andrea Salonia More articles by this author Francesco Montorsi More articles by this author Alessandro Larcher More articles by this author Umberto Capitanio More articles by this author Expand All Advertisement PDF downloadLoading ...

MP64-07 DEVELOPMENT OF AN INDIVIDUAL POSTOPERATIVE PREDICTION MODEL FOR KIDNEY CANCER RECURRENCE USING MACHINE LEARNING (UroCCR STUDY 120)

You have accessJournal of UrologyCME1 Apr 2023MP64-07 DEVELOPMENT OF AN INDIVIDUAL POSTOPERATIVE PREDICTION MODEL FOR KIDNEY CANCER RECURRENCE USING MACHINE LEARNING (UroCCR STUDY 120) Gaëlle Margue, Loïc Ferrer, Guillaume Etchepare, Karim Bensalah, Arnaud Mejean, Morgan Roupret, Nicolas Doumerc, Alexandre Ingels, Romain Boissier, Géraldine Pignot, Bastien Parier, Philippe Paparel, Thibaut Waeckel, Pierre Bigot, and Jean-Christophe Bernhard Gaëlle MargueGaëlle Margue More articles by this author , Loïc FerrerLoïc Ferrer More articles by this author , Guillaume EtchepareGuillaume Etchepare More articles by this author , Karim BensalahKarim Bensalah More articles by this author , Arnaud MejeanArnaud Mejean More articles by this author , Morgan RoupretMorgan Roupret More articles by this author , Nicolas DoumercNicolas Doumerc More articles by this author , Alexandre IngelsAlexandre Ingels More articles by this author , Romain BoissierRomain Boissier More articles by this author , Géraldine PignotGéraldine Pignot More articles by this author , Bastien ParierBastien Parier More articles by this author , Philippe PaparelPhilippe Paparel More articles by this author , Thibaut WaeckelThibaut Waeckel More articles by this author , Pierre BigotPierre Bigot More articles by this author , and Jean-Christophe BernhardJean-Christophe Bernhard More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003322.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Kidney cancer is of increasing incidence worldwide. It is most often diagnosed at a localized stage where surgical management is the gold standard. Current prognostic scores offer moderate predictive performance which leads to difficulties in establishing follow-up recommendations for patients after surgery and selecting patients who could benefit from adjuvant therapy. Our objective is to develop a model for individual prediction of the recurrence risk after surgery using machine learning (ML). METHODS: From the french research network on kidney cancer database UroCCR (NCT 03293563), a cohort of patients undergoing surgery between May 2000 and January 2020 for a localized or locally advanced renal cell carcinoma (pT1-T4, N0, M0) was analyzed. Patients with a genetic cancer, a concomitant malignant disease or a chronic inflammatory disease were excluded. For each patient, clinical, biological, histological, and radiological data were collected.Participating sites were randomly assigned to the training or testing cohort with a 67/33 ratio of patients. Missing data were multiply imputed using the MICE algorithm and gradient boosted trees. Several ML algorithms were trained on the training data set and parameters of each algorithm were optimized using repeated cross-validation procedure. C-index at 5 years was used as optimization metric. The predictive performance of the algorithm was then evaluated on the test dataset using C-index and AUC. RESULTS: In total, 3255 patients were split in training and test cohorts of 2172 and 1083 patients, respectively. The enclosed patients had tumors with a mean size of 4cm and 71% of ccRCC; 3.6% had locoregional recurrence, 7% had metastatic progression and 2.4% died. The median follow-up was 25 months. The best results in DFS prediction were obtained using a Cox PH model including 18 variables with a C-index of 0,75 and an AUC of 0,71 at 5 years. Comparatively, the C-index of the UISS and SSIGN scores were of 0.61 and 0.72. Shapley values graphs were generated to display the predicted DFS and the relative contribution of each feature leading to the personalized prediction. CONCLUSIONS: ML applied to data from patients undergoing surgery for localized kidney cancer appears to provide good individual DFS predictions comparing to usual scores. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e883 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gaëlle Margue More articles by this author Loïc Ferrer More articles by this author Guillaume Etchepare More articles by this author Karim Bensalah More articles by this author Arnaud Mejean More articles by this author Morgan Roupret More articles by this author Nicolas Doumerc More articles by this author Alexandre Ingels More articles by this author Romain Boissier More articles by this author Géraldine Pignot More articles by this author Bastien Parier More articles by this author Philippe Paparel More articles by this author Thibaut Waeckel More articles by this author Pierre Bigot More articles by this author Jean-Christophe Bernhard More articles by this author Expand All Advertisement PDF downloadLoading ...

Variation in the management of cT1 renal cancer by surgical hospital volume: A nationwide study.

To analyse variation in clinical management of cT1 renal cell carcinoma (RCC) in the Netherlands related to surgical hospital volume (HV). Patients diagnosed with cT1 RCC during 2014-2020 were identified in the Netherlands Cancer Registry. Patient and tumour characteristics were retrieved. Hospitals performing kidney cancer surgery were categorised by annual HV as low (HV < 25), medium (HV = 25-49) and high (HV > 50). Trends over time in nephron-sparing strategies for cT1a and cT1b were evaluated. Patient, tumour and treatment characteristics of (partial) nephrectomies were compared by HV. Variation in applied treatment was studied by HV. Between 2014 and 2020, 10 964 patients were diagnosed with cT1 RCC. Over time, a clear increase in nephron-sparing management was observed. The majority of cT1a underwent a partial nephrectomy (PN), although less PNs were applied over time (from 48% in 2014 to 41% in 2020). Active surveillance (AS) was increasingly applied (from 18% to 32%). For cT1a, 85% received nephron-sparing management in all HV categories, either with AS, PN or focal therapy (FT). For T1b, radical nephrectomy (RN) remained the most common treatment (from 57% to 50%). Patients in high-volume hospitals underwent more often PN (35%) for T1b compared with medium HV (28%) and low HV (19%). HV is related to variation in the management of cT1 RCC in the Netherlands. The EAU guidelines have recommended PN as preferred treatmentfor cT1 RCC. In most patients with cT1a, nephron-sparing management was applied in all HV categories, although differences in applied strategy were found and PN was more frequently used in high HV. For T1b, high HV was associated with less appliance of RN, whereas PN was increasingly used. Therefore, closer guideline adherence was found in high-volume hospitals.

Patient experience of follow-up after surgery for kidney cancer: a focus group study.

To explore patient experience of follow-up care after kidney cancer surgery and to develop recommendations for best practice. We conducted two focus groups, including 14 participants with experience of kidney cancer follow-up after surgery, to elicit patient views on current follow-up care. Thematic analysis was used to identify unifying themes to describe the patient experience of follow-up, and the results were then used to develop a set of recommendations for best practice. We identified six themes (feelings of abandonment; uncertainty about the plan; anxiety about appointments; variation in care; a need for information; and a need for emotional support) that described current patient experience and areas in which current care could be improved. In particular, while most of the participants felt that their physical needs had been met, many had struggled with unmet emotional needs and a lack of information and resources. This was especially noted in the period immediately following surgery, when feelings of abandonment were common, and around follow-up scans and routine appointments, which were a source of anxiety. Our participants also described concerns about the lack of consistency between different hospitals and centres around the United Kingdom, with differences in the content and quality of follow-up care. Based on the results, we developed a list of recommendations to address some of the challenges described through relatively minor changes to the care pathway. We identified gaps and variability in current follow-up care after kidney cancer surgery, and have developed a set of recommendations that, if implemented, would improve the follow-up care experience for these patients.

Concordance of renal sinus or calyces invasion between preoperative imaging and final pathology after surgery for kidney cancer

Concordance of renal sinus or calyces invasion between preoperative imaging and final pathology after surgery for kidney cancer