Surgery For Kidney Cancer Research Articles

MP55-12 LONG-TERM ASSESSMENT OF MORTALITY PATTERNS AFTER SURGICAL TREATMENT FOR NON-METASTATIC KIDNEY CANCER: A COMPETING RISK ANALYSIS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy III1 Apr 2017MP55-12 LONG-TERM ASSESSMENT OF MORTALITY PATTERNS AFTER SURGICAL TREATMENT FOR NON-METASTATIC KIDNEY CANCER: A COMPETING RISK ANALYSIS Alessandro Larcher, Alessandro Nini, Fabio Muttin, Francesco Trevisani, Francesco Ripa, Zachary Hamilton, Ithaar Derweesh, Cristina Carenzi, Domenico Fichera, Patrizio Rigatti, Federico Dehò, Francesco Montorsi, Umberto Capitanio, and Roberto Bertini Alessandro LarcherAlessandro Larcher More articles by this author , Alessandro NiniAlessandro Nini More articles by this author , Fabio MuttinFabio Muttin More articles by this author , Francesco TrevisaniFrancesco Trevisani More articles by this author , Francesco RipaFrancesco Ripa More articles by this author , Zachary HamiltonZachary Hamilton More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , Cristina CarenziCristina Carenzi More articles by this author , Domenico FicheraDomenico Fichera More articles by this author , Patrizio RigattiPatrizio Rigatti More articles by this author , Federico DehòFederico Dehò More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Umberto CapitanioUmberto Capitanio More articles by this author , and Roberto BertiniRoberto Bertini More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1705AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Accurate estimation of long-term risk of cancer-specific [CSM] and other-cause mortality [OCM] is of utmost importance for clinical management of patients diagnosed with kidney cancer. The aim of the study is to assess long-term mortality rates of a contemporary cohort of patients surgically treated for non-metastatic kidney cancer. METHODS 1,704 patients with non-metastatic kidney cancer treated with either radical or partial nephrectomy between 1987 and 2015 in a prospectively collected institutional database were assessed. Outcomes of the study were the 10-year rates of CSM and OCM. A multivariable competing risk regression model was fitted to predict CSM and OCM. Covariates consisted of age, gender, Charlson comorbidity index [CCI], pre-operative estimated glomerular filtration rate, haemoglobin and platelets, clinical tumour size, clinical tumour [cT] and nodal stage [cN], presence of local symptoms at diagnosis and year of surgery. Smoothed Poisson's incidence plots were used to estimate 10-year CSM and OCM rates in the overall population as well as in 4 sub-cohorts defined as: A.age =60 and stage T1; B.age >60 and stage T1; C.age =60 and stage >T1; D.age >60 with stage >T1. RESULTS At a median follow-up of 72 months, 10-year rates of CSM and OCM were 11 and 14%, respectively. At competing risk regression analysis, age, platelets, cT and cN resulted associated with higher risk of CSM (all p<0.05). Conversely, female gender and year of diagnosis were associated with lower risk of CSM (all p<0.05). Moreover, age, CCI and tumour size resulted associated with higher risk of OCM (all p<0.05). Conversely, female gender and year of diagnosis were associated with lower risk of OCM (all p<0.05). After stratification according to age and cT (Figure 1), the 10-year CSM and OCM rates resulted 3.4 and 5% in group A; 8 and 24% in group B; 22 and 7.7% in group C and 31 and 24% in group D, respectively. CONCLUSIONS The relative impact on CSM and OCM in patients treated with surgery for kidney cancer is extremely heterogeneous according to host and cancer characteristics. The 10-years rates of CSM and OCM resulted 3.4 and 5% in younger patients with cT1 and 31 and 24% in older patients with cT2 or higher stage. These figures can aid clinical decision making providing a precise long-term mortality risk estimation. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e735 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Alessandro Larcher More articles by this author Alessandro Nini More articles by this author Fabio Muttin More articles by this author Francesco Trevisani More articles by this author Francesco Ripa More articles by this author Zachary Hamilton More articles by this author Ithaar Derweesh More articles by this author Cristina Carenzi More articles by this author Domenico Fichera More articles by this author Patrizio Rigatti More articles by this author Federico Dehò More articles by this author Francesco Montorsi More articles by this author Umberto Capitanio More articles by this author Roberto Bertini More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP55-14 THE ABILITY OF THREE COMORBITY INDECES TO PREDICT POSTOSPERATIVE MORTALITY IN RENAL CELL CARCINOMA PATIENTS: THE IMPENDING NEED OF A NEW DISEASE-SPECIFIC INDEX

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy III1 Apr 2017MP55-14 THE ABILITY OF THREE COMORBITY INDECES TO PREDICT POSTOSPERATIVE MORTALITY IN RENAL CELL CARCINOMA PATIENTS: THE IMPENDING NEED OF A NEW DISEASE-SPECIFIC INDEX Paolo Dell'Oglio, Alessandro Larcher, Fabio Muttin, Francesco Cianflone, Alessandro Nini, Zachary Hamilton, Ithaar Derweesh, Francesco Trevisani, Cristina Carenzi, Andrea Salonia, Alberto Briganti, Francesco Montorsi, Roberto Bertini, and Umberto Capitanio Paolo Dell'OglioPaolo Dell'Oglio More articles by this author , Alessandro LarcherAlessandro Larcher More articles by this author , Fabio MuttinFabio Muttin More articles by this author , Francesco CianfloneFrancesco Cianflone More articles by this author , Alessandro NiniAlessandro Nini More articles by this author , Zachary HamiltonZachary Hamilton More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , Francesco TrevisaniFrancesco Trevisani More articles by this author , Cristina CarenziCristina Carenzi More articles by this author , Andrea SaloniaAndrea Salonia More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Roberto BertiniRoberto Bertini More articles by this author , and Umberto CapitanioUmberto Capitanio More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1707AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To date no studies assessed whether Charlson Comorbidy Index (CCI), American Society of Anesthesiologists score (ASA) and Eastern Cooperative Oncology Group performance status (ECOG) have the same ability to predict postoperative mortality in renal cell carcinoma (RCC) patients who undergo radical (RN) or partial nephrectomy (PN). The aim of the study was to assess the predictive ability of these indeces on other cause mortality (OCM) in patients treated with surgery for kidney cancer. METHODS We identified 2,648 T1-T4 patients treated with RN or PN for RCC between 1987 and 2014 at a single centre. Patients with distant metastases at diagnosis, with multiple lesions and with Von Hippel Lindau were excluded. Four multivariable Cox regression analyses (MVA) were performed to assess OCM predictors. Predictors included in Model 1 were age at surgery and gender (basic model). Predictors in Model 2, 3 and 4 were the same included into Model 1 plus CCI, ASA and ECOG, respectively. The discrimination of the accuracy of each model was quantified using the receiver operating characteristic-derived area under the curve with a time frame at 3-year. Decision curve analyses were performed to evaluate and compare the net-benefit associated with the use of the 3 indeces relative to the basic model. RESULTS 249 patients (9.4%) died of other causes. Overall, 82 (3.1%) patients died within 3 years after surgery. The median follow-up in patients who survived was 63 months (IQR 30-118). At MVA of Model 1, age (HR 1.1) and gender (HR 1.5) were independent predictors of OCM (all p0.004). At MVA of Model 2, 3 and 4, age and gender remained independent predictors of OCM (all p0.04). Furthermore, at MVA of model 2, 3 and 4 CCI (HR 1.3), ASA (HR 1.09) and ECOG (HR 1.9) reached the independent predictor status (all p<0.001). The accuracy of Model 1, 2, 3 and 4 were 74.5 vs 77.6 vs 76.3 vs 76.3. After decision curve analyses, there was no superior net-benefit of one model relative to the others. CONCLUSIONS We provided evidence that the difference in accuracy between the CCI, ASA and ECOG is clinically negligible. Interestingly, the increase in accuracy relative to the basic model of all three index is limited and there is no superior net-benefit of any of the examined indeces relative to the basic model. These findings suggest that there is an impending need of a disease-specific index to predict OCM in RCC patients submitted to surgery. At the moment, clinicians may use any of these indeces for RCC patients counselling to predict postoperative mortality after surgery. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e736 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Paolo Dell'Oglio More articles by this author Alessandro Larcher More articles by this author Fabio Muttin More articles by this author Francesco Cianflone More articles by this author Alessandro Nini More articles by this author Zachary Hamilton More articles by this author Ithaar Derweesh More articles by this author Francesco Trevisani More articles by this author Cristina Carenzi More articles by this author Andrea Salonia More articles by this author Alberto Briganti More articles by this author Francesco Montorsi More articles by this author Roberto Bertini More articles by this author Umberto Capitanio More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Excisional Precision Matters: Understanding the Influence of Excisional Volume Loss on Renal Function After Partial Nephrectomy

Renal function after partial nephrectomy (PN) may depend on modifiable factors including ischemia time, excision of healthy parenchyma (excisional volume loss, EVL), and reconstructive methods. We retrospectively reviewed our institutional robotic PN database to identify the predictors of glomerular filtration rate (GFR) preservation (GFR-P) at 3–12 mo postoperatively, during which GFR decline plateaus. Baseline clinical, sociodemographic, and radiologic characteristics were captured. Univariate and multivariate (MV) linear regression analyses were performed and marginal effects were employed to examine the relative effect of EVL on renal function. A total of 647 patients who underwent robotic PN had GFR data at a median follow-up of 6 mo. On MV models, EVL was significantly correlated with GFR-P following log transformation (p=0.001). Each doubling of EVL caused a 1.5% decrease in GFR-P. Ischemia time and tumor complexity were not significantly associated with GFR-P. In summary, GFR-P after PN appears to be significantly associated with the excised volume of benign parenchyma. Patient summaryAt a high-volume tertiary care center, we investigated the impact of surgical factors on kidney function after kidney cancer surgery. We found that the surgical precision with which the tumor is excised significantly impacts kidney function at 3–12 mo after surgery.

Impact of rural/urban residence on relative survival (RS) in patients with kidney cancer: An analysis of 14576 patients from the Austrian National Cancer Registry (ANCR).

491 Background: Access to medical diagnostics and treatment might be limited for patients living in rural areas compared to urban residents. To evaluate the potential impact of urban/rural residence, we analyzed trends in RS for patients diagnosed with kidney cancer between 1998 and 2009 in Austria. Methods: All patients with kidney cancer aged ≥18 years, diagnosed from 1998-2009 were derived from the ANCR (n=14,576). Patients were categorized into two groups: rural (n=7,537) and urban (n=7,039) based on a complex algorithm considering infrastructure, commuter interrelations, accessibility of centers, and tourism at the time of diagnosis. Relative survival was calculated based on complete follow-up until December 31st, 2014. Poisson regression modeling was used to evaluate survival differences between the two groups and to calculate the relative excess risk of dying (RER). Analyses were performed for the total patient population and primary metastatic patients (M+). Results: Distribution of sex, age, stage of disease, year of diagnosis, and surgical treatment did not differ between rural and urban patients. Five-year RS was 74% for rural compared to 73% for urban patients (RER for rural: 0.88, 95% CI 0.81-0.95). In M+ patients, 5-year RS was 14% for both residence groups. On multivariate analysis, residence remained as an independent predictor for survival in the overall kidney cancer population (RER of rural patients 0.87, 95% CI 0.81-0.94). For M+ patients the RER was 0.90 ( 95% CI 0.81-1.00). For patients without surgery, rural patients were even stronger benefited in their survival than urban patients (overall population: RER 0.81, 95% CI 0.74-0.89; M+ patients: RER 0.84, 95% CI 0.73-0.97) wherereas in surgical patients RS did not differ between rural and urban patients. Conclusions: An advantage in RS was observed for kidney cancer patients living in rural areas. This advantage was evident in metastatic and non-metastatic patients, especially in patients who did not undergo surgery for (metastatic) kidney cancer. These results suggest that access to medical health care for kidney cancer patients in Austria is not limited by rural residence.

The Dynamics of Acute Renal Impairment Markers During a Surgery for Kidney Cancer

The purpose of the study is to investigate the effect of epidural block on the functional state of the kidneys in patients with localized cancer during kidney resection under the conditions of warm ischemia. Materials and methods. We examined 45 patients (25 men and 20 women) with a localized kidney cancer (T1N0M0) aged 56.5±8.7 years. All the patients underwent kidney resection performed under conditions of warm ischemia (15—20 minutes). Patients were divided into 2 groups: the main group (25 subjects) in which the perioperative epidural block was applied and the reference group (20 patients) without the epidural block. The following parameters were tested in blood and urine using the ELISA technique: cystatin C, L-FABP, KIM-1 , IL-18, and GFR. The test was carried out 1 hour prior to surgery, 20 minutes after the warm ischemia stage, and on Days 1 and 3. Based on the baseline cystatin С level, the patients in each group were divided into 2 subgroups: subgroup 1 —cystatin C is 1000 ng/ml and lower; subgroup 2 — more than 1000 ng/ml. The statistical processing of the findings was performed using the Statistica 6.0 software based on the t-test for two independent samples. Differences were considered to be statistically significant at P<0.05. Results . It has been demonstrated that functional parameters of kidneys were recovered to the baseline values by the 3rd day after the kidney resection under the warm ischemia due to perioperative epidural block. Impairment of the tubulointerstitium and glomerular apparatus were observed in the reference group. GFR values in the patients of the main group were within normal limits by Day 3, whereas in the patients of the GFR was lower by 38.8% as compared to the baseline (P<0.05). Conclusion. The use of the perioperative epidural block in patients with localized kidney cancer who underwent the organ resection under the warm ischemia demonstrated the nephroprotective effect, while maintaining the functional parameters of kidneys at the baseline level.

The activity of proapoptotic genes increases after renal ischemia/reperfusion

According to the World Health Organization, pathologies associated with ischemia/reperfusion occupy the leading position in the structure of mortality. The efficiency of localized kidney cancer surgery is limited by the damaging effects of prolonged warm ischemia and reperfusion. Ischemia/reperfusion damage to renal tissue may be related to changes in the expression profiles of pro- and antiapoptotic genes. Here, we have presented the longitudinal expression profiles of apoptosis-related genes in tissues of left and right (intact) kidneys of male rats exposed to unilateral ischemia followed by reperfusion. The profiles have been assessed at time points of 1, 3, and 48 h after the ischemic/reperfusion exposure by RT-qPCR quantification of mRNAs encoded by 13 genes, including BAX, p53, AIFM1, APAF1, CASP8, CASP3, CASP9,CASP7, MDM2, BCL2, CIAP1, XIAP, and ICAD, after normalization with respect to a reference gene ACTB. The study revealed a shift in the expression of pro- and antiapoptotic genes toward the predominance of proapoptotic processes, as was evinced by the increase in expression detected for the BAX, p53, AIFM1, APAF1, and CASP8 genes. One hour after the reperfusion, activation of mitochondrial, or intrinsic apoptosis was detected, while р53-dependent and extrinsic, i.e., receptor-driven, apoptosis joined at later time points. Changes in the level of expression of caspase 7 (CASP7)-encoding mRNA have only been detected 48 h after the restoration of blood flow. Changes have been observed in the transcription of pro- and antiapoptotic genes in tissues of both kidneys, which suggests the involvement of the contralateral kidney in systemic pathological process that develops during unilateral ischemia/reperfusion.

Patient Function and the Value of Surgical Care for Kidney Cancer

Frailty and functional status have emerged as significant predictors of morbidity and mortality for patients undergoing cancer surgery. To articulate the impact on value (ie quality per cost), we compared perioperative outcomes and expenditures according to patient function for older adults undergoing kidney cancer surgery. Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data, we identified 19,129 elderly patients with kidney cancer treated with nonablative surgery from 2000 to 2009. We quantified patient function using function related indicators (claims indicative of dysfunction and disability) and measured 30-day morbidity, mortality, resource use and cost. Using multivariable, mixed effects models to adjust for patient and hospital characteristics, we estimated the relationship of patient functionality with both treatment outcomes and expenditures. Of 19,129 patients we identified 5,509 (28.8%) and 3,127 (16.4%) with a function related indicator count of 1 and 2 or greater, respectively. While surgical complications did not vary (OR 0.95, 95% CI 0.86-1.05), patients with 2 or more indicators more often experienced a medical event (OR 1.22, 95% CI 1.10-1.36) or a geriatric event (OR 1.55, 95% CI 1.33-1.81), or died within 30 days of surgery (OR 1.43, 95% CI 1.10-1.86) compared with patients with no baseline dysfunction. These patients utilized significantly more medical resources and amassed higher acute care expenditures (p <0.001). During kidney cancer surgery, patients in poor functional health can face a more eventful medical recovery at elevated cost, indicating lower value care. Greater consideration of frailty and functional status during treatment planning and transitions may represent areas for value enhancement in kidney cancer and urology care.

Health status and use of partial nephrectomy in older adults with early-stage kidney cancer

IntroductionThe long-term benefits of nephron-sparing surgery for kidney cancer depend on patient health. Accordingly, we examined whether receipt of partial nephrectomy varied with baseline comorbidity or functionality among older adults with stage I kidney cancer. Materials and methodsUsing Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2000 to 2009, we identified patients treated with partial or radical nephrectomy for stage I kidney cancer. We examined treatment trends according to baseline comorbidity, function, and relevant health conditions. We then estimated the probability of partial nephrectomy using multivariable, mixed-effects models adjusting for patient, surgeon, and hospital characteristics. ResultsOverall, 2,956 of 11,678 patients (25.3%) underwent treatment with partial nephrectomy. Receipt of partial nephrectomy was associated with younger age, male sex, higher socioeconomic position, smaller tumor size, and treatment by a high-volume provider, cancer center, or academic institution (P<0.001). During the study period, utilization increased significantly (P<0.001) but did not differ according to comorbidity or patient function. Adjusting for patient, surgeon, and hospital characteristics, the probability of partial nephrectomy by comorbidity and function categories remained within a narrow range from 19.6% to 22.8%. Only preexisting kidney disease appeared to be linked to partial nephrectomy usage (odds ratio = 1.49, 95% CI: 1.33–1.66). ConclusionWith the exception of kidney disease, the increasing use of partial nephrectomy did not vary with respect to health status. As the potential benefits of partial nephrectomy differ according to a patient׳s underlying health, selection tools and algorithms that match treatment to patient comorbidity or function may be needed to optimize kidney cancer care in the United States.

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

BackgroundTo 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. ObjectivesTo compare the impact of hospital volume on outcome with regard to 30-d mortality (TDM) following KC surgery. Design, setting, and participantsWe 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 analysisRelationships with outcome were analysed using multivariate logistic regression. Results and limitationsIn 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. ConclusionsTDM is associated with age, stage, and hospital volume. The study supports the new regulation for hospital volume introduced in Norway. Patient summaryThe 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.

Influences of the network medical health management on the coping styles, hope level and quality of life in patients with primary kidney cancer surgery

Objective To explore the influences of the network medical health management on the coping styles, hope level and quality of life in patients with primary kidney cancer surgery. Methods The patients of control group received normal health management and the participants included 77 kidney cancer patients who were laboratory diagnosed during March 2011 and September 2012. The patients of intervention group received the network medical health management based on the normal health management and the participants included 79 kidney cancer patients who were laboratory diagnosed during March 2013 and September 2014. The coping styles, hope level and quality of life before and after the intervention were compared between the two groups. Results Before the intervention, the coping styles and the hope level had no statistical differences between the two groups (P>0.05). After the intervention for the coping styles, the intervention group had higher scores of the positive coping style (25.44±2.61) and lower scores of the negative coping style (9.76±1.89) and presented statistical differences compared with that of the control group (t=-10.468, 7.572; P 0.05); however, after intervention, the intervention group had higher scores of positive attitudes (14.5±2.6), positive behaviors (15.1±2.4) and close contact with people (15.6±2.1), and presented statistical differences with that of the control group (t=4.965, 5.569, 4.965; P 0.05) but the intervention group performed better on other 12 dimensions′ scores (P<0.05); the quality of life in the intervention group was better than that of control group. Conclusions The network medical health management should be further applied to the clinical practice, because it can significantly improve the coping styles, hope level and quality of life among the patient with primary kidney cancer surgery. Key words: Health management; Quality of life; Hope level; Network medicine; Coping style

Life Expectancy and Variation in Treatment for Early Stage Kidney Cancer

Patients with limited life expectancy are at risk for overtreatment of T1a kidney cancer. We sought to determine patterns of treatment for T1a kidney cancer in a nationally representative sample of patients with life expectancy less than 10 and less than 5 years. We sampled 9,825 patients older than 65 years with clinical T1a kidney cancer diagnosed between 2000 and 2010 from the SEER (Surveillance, Epidemiology and End Results)-Medicare database. We performed competing risks regression to model survival by age/comorbidity and identified patients with life expectancy less than 10 and less than 5 years. Multivariate logistic regression was used to determine the probability of aggressive treatment with surgery or ablation among those with limited life expectancy. Life expectancy was less than 10 years in patients 66 to 80 years old with a Charlson score of 3+, in those 80 to 84 years old with a Charlson score of 1+ and in all patients 85 years old or older. Among those with life expectancy less than 10 years the multivariate probability of aggressive treatment was 85%, 84%, 82%, 75% and 50% in those 66 to 69, 70 to 74, 75 to 79, 80 to 84 and 85 years old or older, respectively. In those with life expectancy less than 10 years who were treated aggressively treatment was radical nephrectomy in 61%, partial nephrectomy in 24% and ablation in 14%. Among those with life expectancy less than 5 years (age 85 years or greater with a Charlson score of 3+) the multivariate probability of aggressive treatment was 41% and more often surgery than ablation (68% vs 32% of patients). The majority of patients with life expectancy less than 10 years and a significant minority with life expectancy less than 5 years were treated with surgery or ablation for T1a kidney cancer. Life expectancy should be better incorporated into treatment decision making for early stage kidney cancer.

Utility of nephrometric scores in kidney cancer surgery

Utility of nephrometric scores in kidney cancer surgery

Low yield of surveillance imaging after surgery for T1 kidney cancer.

To examine the mode of relapse detection and subsequent treatment after partial or radical nephrectomy in patients with low-risk (pT1, N0, Nx) kidney cancer. Retrospective study on 1404 patients treated with partial or radical nephrectomy for low-risk kidney cancer from the years 2000-2012. Scans for chest imaging (X-ray or CT) and abdominal imaging (CT, MRI, or ultrasound) are tabulated. For those patients with relapse, the site, mode of detection, and symptoms were recorded. Twenty-one patients relapsed with a median follow-up of 4.1years for patients who did not relapse. In 17 (81%) patients, relapse was detected by imaging alone, while 4 (19%) patients presented with symptoms. Of the patients who relapsed by imaging, 13 (76%) were treated immediately, while 4 (24%) continued observation. During the first 3years of follow-up, 5762 imaging studies were performed to detect 8 relapses, with 6 patients receiving immediate treatment. The median number of imaging studies per patient per year for the first 3years was 1.7 (interquartile range 1.0, 2.3) including 30% CT, 3% MRI, 36% X-ray, and 31% ultrasounds. We found a low yield of surveillance imaging in the first 3years for pT1 kidney cancer. Nearly 1000 imaging studies were performed to detect one relapse that required treatment. Further studies are needed to evaluate the clinical impact of imaging surveillance according to recent guidelines.

Use of complementary and alternative medicine before and after organ removal due to urologic cancer

ObjectiveMany patients use complementary and alternative medicine (CAM) as primary treatment or symptom relief for a variety of illnesses. This study was designed to investigate the influence of surgical removal of a tumor-bearing urogenital organ on CAM use.MethodsFrom 2007 to 2011, 350 patients underwent major urological surgery for kidney, prostate, or bladder cancer at the Goethe-University Hospital, Frankfurt, Germany. Data from 172 patients (49%), who returned a questionnaire, were retrospectively evaluated using the hospital information system along with the questionnaire to objectify CAM use 2 years before and after surgery.ResultsFrom the 172 patients returning questionnaires, 56 (33%) used CAM before and/or after surgery and 116 (67%) never used CAM. Of the 56 CAM users, 30 (54%) used CAM presurgery and 53 (95%) used CAM postsurgery, indicating a significant change of mind about CAM use. Patients of German nationality used CAM significantly more than patients of other nationalities. Higher educational status (high-school diploma or higher) was a significant factor in favor of CAM use. The most common type of CAM used before/after surgery was an alternative medical system (63/49%), a manipulative and body-based method (50/19%), and a biological-based therapy (37/32%). Information about CAM, either provided by medical professionals or by other sources, was the main reason determining whether patients used CAM or not.ConclusionThe number of patients using CAM almost doubled after surgical removal of a cancer-bearing organ. Better awareness and understanding of CAM use by medical professionals could improve patient counseling.

Compared With Radical Nephrectomy, Nephron-sparing Partial Nephrectomy Protects Apolipoprotein E–deficient Mice From Atherosclerosis Progression

To compare the effect of radical with partial unilateral nephrectomy on the development of atherosclerosis in the apolipoprotein E (apoE(-/-))-deficient mouse model. Male apoE(-/-) mice were randomly assigned to the following 3 groups: (1) radical left nephrectomy (RNX, 15 mice), (2) partial left nephrectomy (PNX, 15 mice), and (3) left kidney sham operation (sham-op, 12 mice). The right kidney was left intact in all groups. At 16 weeks after surgery, mice were killed, and atherosclerotic surface area and plaque composition were evaluated in the aortic root and the descending aorta using a quantitative morphologic image processing method. At killing, RNX mice had significantly higher serum urea, total cholesterol, and triglyceride concentrations than PNX and sham-op groups (P <.05, P <.001, and P <.0001, respectively). Atherosclerotic lesions in the aortic root and the descending aorta were significantly increased in the RNX mice compared with those in the PNX and sham-op mice (P <.05 and P <.001, respectively). In addition, aortic plaques of RNX mice showed a significant increase in nitrotyrosine expression (P <.02) and collagen content (P <.05), whereas the degree of macrophage infiltration was comparable between the groups. We show for the first time that PNX, as compared with RNX, slows the progression of vascular disease in a mouse model of severe atherosclerosis. This effect was mediated by the prevention of chronic kidney disease-induced increases in oxidative stress and lipid disturbances. Our finding can be interpreted as being in support of an expanded use of nephron-sparing techniques in atherosclerosis-prone patients who need to undergo kidney cancer surgery.

MP84-02 DIFFERING KIDNEY FUNCTION OUTCOMES FOLLOWING KIDNEY CANCER SURGERY IN THE VETERANS HEALTH ADMINISTRATION

You have accessJournal of UrologyKidney Cancer: Surgical Therapy VII1 Apr 2015MP84-02 DIFFERING KIDNEY FUNCTION OUTCOMES FOLLOWING KIDNEY CANCER SURGERY IN THE VETERANS HEALTH ADMINISTRATION Remy Lamberts, I-Chun Thomas, Benjamin Chung, Geoffrey Sonn, Alice Fan, Sandy Srinivas, Todd Wagner, Glen Chertow, James Brooks, and John Leppert Remy LambertsRemy Lamberts More articles by this author , I-Chun ThomasI-Chun Thomas More articles by this author , Benjamin ChungBenjamin Chung More articles by this author , Geoffrey SonnGeoffrey Sonn More articles by this author , Alice FanAlice Fan More articles by this author , Sandy SrinivasSandy Srinivas More articles by this author , Todd WagnerTodd Wagner More articles by this author , Glen ChertowGlen Chertow More articles by this author , James BrooksJames Brooks More articles by this author , and John LeppertJohn Leppert More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1969AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Veterans Health Administration (VHA) is the largest integrated national health care system in the US. The VHA has a standardized electronic medical record, including measures of vital signs, laboratory values, and cancer specific data. Users of the VHA diagnosed with kidney cancer tend to be older, have more comorbid conditions, and may be more sensitive to changes in kidney function following kidney cancer surgery. We sought to characterize the change in kidney function across a national contemporary cohort following radical (RN) or partial nephrectomy (PN). METHODS We created a national cohort of patients undergoing RN or PN in the VHA using procedure codes from 2000-2013. We then extracted tumor specific data for patients with entries in the VA Oncology data (CDW) and all measures of kidney function from the laboratory data (DSS). We characterized pre-operative kidney function using the most recent measure, an average of the values over 12 months prior to surgery, and imputed the kidney function on the day of surgery using generalized linear regression. We characterized post-operative kidney function using all available measurements. We imputed kidney function at specific time points to estimate the magnitude of the difference in kidney function between the two surgical approaches. Finally, we fit time to event and proportional hazards models to test the association with radical nephrectomy and the outcome of significant chronic kidney disease (eGFR<30 or claims for ESRD or dialysis) for patients with normal or near normal preoperative kidney function (eGFR >=45). RESULTS We identified a cohort of 9278 patients that underwent kidney cancer surgery with either RN (n=6151) or PN (n=3127). The vast majority of patients had multiple pre- (median 15) and post-operative (median 20) serum measurements of creatinine identified in the VHA. Mean serum pre-operative creatinine values were similar (1.09 vs. 1.1). However, eGFR was higher among patients treated with RN. A contour plot of the 153,470 post-operative eGFR measurements following kidney cancer surgery is shown in the figure. CONCLUSIONS The VHA provides opportunity to measure the change in kidney function following kidney cancer surgery in a national health care system. Integrated health care data can facilitate comparative effectiveness studies with long-term data. PN preserves renal function in an predominantly male, comorbid population. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1058 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Remy Lamberts More articles by this author I-Chun Thomas More articles by this author Benjamin Chung More articles by this author Geoffrey Sonn More articles by this author Alice Fan More articles by this author Sandy Srinivas More articles by this author Todd Wagner More articles by this author Glen Chertow More articles by this author James Brooks More articles by this author John Leppert More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robot-assisted surgery for kidney cancer increased access to a procedure that can reduce mortality and renal failure.

Surgeons increasingly use robot-assisted minimally invasive surgery for a variety of medical conditions. For hospitals, the acquisition and maintenance of a robot requires a significant investment, but financial returns are not linked to any improvement in long-term patient outcomes in the current reimbursement environment. Kidney cancer provides a useful case study for evaluating the long-term value that this innovation can provide. Kidney cancer is generally treated through partial or radical nephrectomy, with evidence favoring the former procedure for appropriate patients. We found that robot-assisted surgery increased access to partial nephrectomy and that partial nephrectomy reduced mortality and renal failure. The value of the benefits of robot-assisted minimally invasive surgery to patients, in terms of quality-adjusted life-years gained, outweighed the health care and surgical costs to patients and payers by a ratio of five to one. In addition, we found no evidence that the availability of robot-assisted minimally invasive surgery increased the likelihood that inappropriate patients received partial nephrectomy.

Renal surgery for kidney cancer in Germany 2005–2006: length of stay, risk of postoperative complications and in-hospital death

BackgroundRepresentative statistics of surgical care among patients with kidney cancer are scant. With the introduction of the diagnosis related group system in Germany, it is now possible to provide nationwide statistics on surgical care. We studied in-hospital mortality risk in relation to comorbidity and complications, length of hospital stay in relation to surgical approach and comorbidity, and risk of complications in relation to surgical approach among kidney cancer patients undergoing nephrectomy.MethodsWe analyzed the nationwide hospitalization file of the years 2005 and 2006 including 23,753 hospitalizations with a diagnosis of renal cancer and partial or complete nephrectomy and classified comorbidity (Charlson comorbidity index) and complications. Length of stay, risk of in-hospital complications and in-hospital death were analyzed by linear regression and log-linear regression (relative risks (RR) and 95% confidence intervals (95% CI)).ResultsThe overall in-hospital mortality was 1.4%. Per one unit increase of the Charlson comorbidity index, the adjusted risk of in-hospital mortality increased by 53% (95% CI 47-59%). The risks of bleeding or acute posthaemorrhagic anemia, respiratory, urological and gastrointestinal complications and infections ranged between 1.1% and 2.7% with the exception of bleeding or acute posthaemorrhagic anemia with 18.4%. Complications were associated with an increased adjusted in-hospital mortality risk. Highest adjusted mortality risk ratios were observed for gastrointestinal (RR = 3.61, 95% CI 2.32-5.63) and urological complications (RR = 3.62, 95% CI 2.62-5.00). The risk of haemorrhage or acute posthaemorrhagic anemia was lower for total laparoscopic nephrectomies than total open nephrectomies. The adjusted risk of gastrointestinal complications was lower for partial open compared to total open nephrectomy (adjusted RR = 0.66, 95% CI 0.45-0.97). Total laparoscopic nephrectomy was associated with shorter length of stay (−3.3 days; 95% CI 2.9-3.7 days) compared to total open nephrectomy. The estimated age-adjusted increase of length of stay per one unit increase of the Charlson comorbidity index was 1.3 days (95% CI 1.2-1.4 days).ConclusionsIn this representative population-based analysis, we found that the surgical approach is associated with the risk of complications and length of hospital stay. Furthermore, in the era of ageing populations, renal cancer patients with comorbidities should be counseled about their increased in-hospital mortality risk.

Identification of quality improvement opportunities in kidney cancer surgery through a regional hospital-based urologic quality collaborative.

413 Background: Patient selection for radical (RN) and partial nephrectomy (PN) for suspicion of kidney cancer may depend more on provider factors than patient characteristics. Observational data suggests that patients with small renal tumors have better overall survival when managed with PN rather than RN. We prospectively evaluated perioperative processes of care for patients undergoing kidney cancer surgery at Washington State hospitals participating in a surgical collaborative to identify quality improvement opportunities in kidney cancer care. Methods: We developed a chart abstraction tool that captures potential quality concerns in kidney cancer surgical care. The abstraction tool was implemented at nine regional hospitals with data consolidated for review quarterly. A sampling of PN and RN cases was abstracted. Hospital-specific feedback reports were blinded to hospital identity; data were analyzed as aggregate rates and hospital-specific rates using descriptive statistics. Presented results were not risk-adjusted. Results: We identified 75 patients undergoing RN or PN at 9 area hospitals from 2011-2013. Staging evaluations were uncommon (preoperative chest x-ray and chest CT in 41% and 20%, respectively). 13% percent of patients had a preoperative renal mass biopsy. For renal tumors ≤ 4 cm, 16/32 (50%) underwent PN. Hospital-specific utilization of PN for small renal masses exhibited variation: in 2 hospitals, 100% of tumors ≤ 4 cm were treated with PN, while 1 hospital performed RN in all cases, and the remaining hospitals ranged from 33%-67% utilization of PN. PN was less common for tumors 4-7 cm in size (4/26 cases [15%]). Venous thromboembolic events occurred in 4% of kidney cancer surgeries. Conclusions: We identified substantial variation in selection of surgical technique and postoperative outcomes following PN and RN for kidney cancer. Patients with small renal masses appear to have variable access to PN, which could impact their long-term health outcomes. Better understanding of provider knowledge and attitudes toward management of small renal masses could inform quality improvement initiatives to address the variations in care identified.

Association of partial nephrectomy and presence of robotic surgery for kidney cancer in the United States.

484 Background: While hospital and surgeon characteristics are associated with the type of nephrectomy performed for renal cell carcinoma (RCC), it is unknown whether hospital presence of robotic surgery increases the likelihood of patients receiving partial nephrectomy (PN). Therefore, we evaluate the relationship of PN and hospital presence of robotic surgery from a population-based cohort in the U.S. Methods: After merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association (AHA) survey from 2006 to 2008, we identified 21,999 patients who underwent either PN or radical nephrectomy (RN) for RCC. The primary outcome of this study was the type of nephrectomy performed. Multivariable logistic regression was used to identify hospital characteristics associated with receipt of PN, after adjusting for patient case mix. Results: Overall, we identified 4,832 (22.0%) and 16,347 (88.0%) patients who were surgically treated for RCC with PN and RN, respectively. On multivariable analysis, patients undergoing surgery were more likely to receive PN at academic (OR: 2.77;p&lt;0.001), urban (OR: 3.66; p&lt;0.001), and American College of Surgeon (ACOS) designated cancer centers (OR: 1.10; p&lt;0.05) compared to non-academic, rural, and non-designated hospitals, respectively. After adjusting for patient and hospital characteristics, patients undergoing surgery at hospitals with presence of robotic surgery were also associated with higher adjusted odds ratios for receipt of PN compared to those treated at hospitals without the presence of this advanced treatment technology (OR: 1.28; p&lt;0.001). Conclusions: While academic status and urban locations are established characteristics influencing the type of nephrectomy performed for RCC, ACOS cancer center designation and hospital presence of robotic surgery were also associated with higher use of PN. Our results are informative in identifying key hospital characteristics which may facilitate greater adoption of PN.