Kidney Sparing Research Articles

Clinical Significance of Tumor Location for Ureteroscopic Tumor Grading in Upper Tract Urothelial Carcinoma.

Background: Although previous literature shows tumor location as a prognostic factor in upper tract urothelial carcinoma (UTUC), there remains uninvestigated regarding the impact of tumor location on grade concordance and discrepancies between ureteroscopic (URS) biopsy and final radical nephroureterectomy (RNU) pathology. Methods: In this international study, we retrospectively reviewed the records of 1,498 patients with UTUC who underwent diagnostic URS with concomitant biopsy followed by RNU between 2005 and 2020. Tumor location was divided into four sections: the calyceal-pelvic system, proximal ureter, middle ureter, and distal ureter. Patients with multifocal tumors were excluded from the study. We performed multiple comparison tests and logistic regression analyses. Results: Overall, 1,154 patients were included; 54.4% of those with low-grade URS biopsies were upgraded on RNU. In the multiple comparison tests, middle ureter tumors exhibited the highest probability of upgrading, meanwhile pelvicalyceal tumors exhibited the lowest probability of upgrading (73.7% vs 48.5%, p = 0.007). Downgrading was comparable across all tumor locations. On multivariate analyses, middle ureteral location was significantly associated with a low probability of grade concordance (odds ratio [OR] 0.59; 95% confidence interval [CI], 0.35-1.00; p = 0.049) and an increased risk of upgrading (OR 2.80; 95% CI, 1.20-6.52; p = 0.017). The discordance did not vary regardless of caliceal location, including the lower calyx. Conclusions: Middle ureteral tumors diagnosed to be low grade had a high probability to be undergraded. Our data can inform providers and their patients regarding the likelihood of undergrading according to tumor location, facilitating patient counseling and shared decision making regarding the choice of kidney sparing vs RNU.

Comparative outcomes of radical nephroureterectomy and kidney-sparing surgery in the treatment of high-grade upper tract urothelial carcinoma.

607 Background: Patients with upper tract urothelial carcinoma (UTUC) can be managed with either radical nephroureterectomy (RNU) or kidney sparing surgery (KSS) depending on the pathology and patient specific characteristics. Due to the rarity of this disease, high-level evidence is lacking with regard to clinical and oncologic outcomes after surgery. This study aims to compare outcomes of RNU with KSS for patients with high-grade (HG) UTUC. Methods: We retrospectively reviewed patients with >1 year follow-up who were treated for HG UTUC at our institution from 2015-2021. Oncologic and clinical outcomes were recorded. Procedure-related burdens, including total number of procedures under anesthesia, anesthesia time, and days hospitalized were collected. Results: 65 patients were analyzed, with 46 patients treated via RNU and 19 treated via KSS. There were no differences in the ASA or CCI between patients in the two groups. The 5-year overall survival (OS) was 65.2% (95% CI, 52.8%-80.5%) for RNU and 44.4% (95% CI, 26.5%-74.5%) for KSS. The 3-year metastasis-free survival was 78.3% for RNU and 78.9% for KSS. The 3-year recurrence-free survival, including recurrences in the bladder, was 47.8% (95% CI, 35.4%-64.7%) for RNU and 43.8% (95% CI, 25.1%-76.3%) for KSS. A decline of GFR <10 2 years after surgery occurred in 97.1% of patients treated with RNU and 100.0% of those treated with KSS. The total number of procedures under anesthesia was higher for KSS than RNU at 3.4 +/- 1.7 vs 2.1 +/- 1.7, respectively (p = 0.0155). The total number of TURBTs for KSS and RNU was similar at 0.6 +/- 0.7 vs 1.1 +/- 1.7, respectively (p = 0.9538). The total number of days hospitalized for KSS was similar to RNU at 5.5 +/- 4.3 vs 6.8 +/- 4.6, respectively (p = 0.3579). The total anesthesia time for KSS was 400 +/- 218 min and was 474 +/- 185 min for RNU (p = 0.2561). Conclusions: There were similar oncologic and clinical outcomes in patients with HG UTUC treated with either KSS or RNU. Patients treated with KSS saw a higher procedural load. There was a trend towards lower OS for patients treated with KSS but this was not statistically significant, likely due to the small sample size. Larger datasets are needed to further evaluate outcome and treatment burdens of RNU vs KSS as treatment options for patients with HG UTUC. [Table: see text]

Systemic and surgical treatment in renal cell carcinoma: Does timing matter?

417 Background: Today, targeted systemic therapy is standard 1st line treatment of advanced/metastatic renal cell carcinoma (aRCC). Upfront cytoreductive nephrectomy (CN) has been an important treatment option. Recently its role is under debate, especially in combination with the new 1st line treatments. Our study evaluated the current relevance of initial surgical intervention and the role of inductive systemic therapy in aRCC. Methods: We included 33 patients with aRCC from the University Hospitals in Essen and Münster initiating 1st line treatment from 03/18 to 01/23 pre or post surgery. We retrospectively formed two cohorts, either CN followed by systemic therapy (cohort 1; 13 patients) or vice versa (cohort 2; 20 patients). Patients received either Ipilimumab/Nivolumab (Ipi/Nivo) (42.4%) or a checkpoint inhibitor and tyrosine kinase inhibitor (CPI/TKI) combination (57.6%). Progression-free survival (PFS) was estimated with Kaplan-Meier-method from initiation of systemic therapy or CN to progression or death. In Cohort 2, we additionally analyzed the radiologic response of the primary measured by change of the longest diameter. The radiographic response was analysed according to RECIST1.1. Results: Patients’ age ranged from 44 to 80 years with a median of 63 years. Intermediate and poor prognosis occurred in 61.3% and 38.7% of cases. The two cohorts did not differ significantly regarding baseline characteristics. Median PFS was 8 vs. 23 months (p=0.03) in cohort 1 (95% CI 0.9-15.1) compared to cohort 2 (95% CI 18.8-27.2). In cohort 2 the time between start of systemic therapy and surgery was in median 8.5 months (95% CI 3.3-21.1), the primary had a median diameter of 10.7 cm (95% CI 4.5-13.3). Median reduction of the primary was in total 32.2%, 28.9% in the Ipi/Nivo and 34.7% in the CPI/TKI group (p=0.74). In seven patients (35%) response led to modification of the surgical approach, enabling partial instead of radical nephrectomy. Conclusions: The sequence of systemic therapy followed by surgery was associated with a significant PFS benefit. In addition, prior systemic therapy led to a primary reduction and better operability, in some cases even to kidney sparing surgery. Major limitation is the retrospective nature of our analysis and a potential selection bias. However, the sequence of prior systemic therapy followed by surgery in aRCC was associated with notably better outcomes.

Kidney sparing surgery in upper tract urothelial carcinoma: paradigm change in surgical treatment for ureter cancer.

To extend the indications of kidney-sparing surgery (KSS) for ureter cancer by comparing the oncological outcomes between patients with upper tract urothelial carcinoma (UTUC) who underwent radical nephroureterectomy (RNU) or KSS. We retrospectively reviewed 708 patients with UTUC who underwent RNU (N = 646) or KSS (N = 62) between 2011 and 2019 to analyze the oncologic outcomes and prognostic factors. Subgroup analyses were performed for patients with unifocal ureteral urothelial carcinoma (UC). No significant difference was observed in the overall survival (OS) or cancer-specific survival (CSS) between RNU and KSS (distal ureterectomy with reimplantation (N = 33), ureterectomy with ileal ureter (N = 14), ureteroscopic tumor resection (N = 10), and ureterectomy with ureteroureterostomy (N = 5)). Among 269 (38.0%) patients with unifocal ureteral UC, 219 and 50 patients underwent RNU and KSS, respectively. OS and CSS were not significantly different between these two groups. Pathologic stage was a significant risk factor in multivariate analysis (hazard ratio = 2.621; p = 0.000). Among 646 RNU patients, 219 (33.9%) had unifocal ureteral UC, 40 (18.3%) with low-grade tumors. Among these, 13 (5.9%) patients with unifocal, low-grade and small (< 2cm) tumors received nephroureterectomy. Kidney-sparing surgery should be regarded as an important alternative to RNU for patients with unifocal ureteral UC thought to have noninvasive disease to preserve renal function and reduce overtreatment.

Segmental ureterectomy for high-risk ureteral carcinoma: a preliminary report

BackgroundEAU guidelines strongly recommend kidney sparing surgery (KSS) as the primary treatment option for the low-risk UTUC patients. While there are few reports involving the KSS treated for the high-risk counterparts, especially the ureteral resection.ObjectiveTo evaluate the effectiveness and safety of the segmental ureterectomy (SU) for the patients with high-risk ureteral carcinoma.Materials and methodsWe included 20 patients from May 2017 to December 2021 who underwent segmental ureterectomy (SU) in Henan Provincial People’s Hospital. The overall survival (OS) and progression free survival (PFS) were evaluated. Besides, the ECOG scores and postoperative complications were also included.ResultsAs of December 2022, the mean OS was 62.1months (95%CI:55.6-68.6months) and the mean PFS was 45.0months (95%CI:35.9-54.1months). The median OS and median PFS were not reached. The 3-year OS rate was 70% and the 3-year PFS rate was 50%. The percentage of Clavien I and II complications was 15%.ConclusionFor the selected patients with high-risk ureteral carcinoma, the efficacy and safety of segmental ureterectomy were satisfactory. But we still need to conduct prospective or randomized study to validate the value of SU in patients with high-risk ureteral carcinoma.

Diagnosis and Management of Non-Metastatic Upper Tract Urothelial Carcinoma: AUA/SUO Guideline

The purpose of this guideline is to provide a useful reference on the effective evidence-based diagnoses and management of non-metastatic upper tract urothelial carcinoma (UTUC). The Pacific Northwest Evidence-based Practice Center of Oregon Health & Science University (OHSU) team conducted searches in Ovid MEDLINE (1946 to March 3rd, 2022), Cochrane Central Register of Controlled Trials (through January 2022), and Cochrane Database of Systematic Reviews (through January 2022). The searches were updated August 2022. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (Table 1).[Table: see text]Results:This Guideline provides updated, evidence-based recommendations regarding diagnosis and management of non-metastatic UTUC including risk stratification, surveillance and survivorship. Treatments discussed include kidney sparing management, surgical management, lymph node dissection (LND), neoadjuvant/adjuvant chemotherapy and immunotherapy. This standardized guideline seeks to improve clinicians' ability to evaluate and treat patients with UTUC based on available evidence. Future studies will be essential to further support these statements for improving patient care. Updates will occur as the knowledge regarding disease biology, clinical behavior and new therapeutic options develop.

P151 - Follow-up after kidney sparing surgery in upper tract urothelial carcinoma, an overview of 10 year contemporary data; Do we need to adjust current follow up protocol?

P151 - Follow-up after kidney sparing surgery in upper tract urothelial carcinoma, an overview of 10 year contemporary data; Do we need to adjust current follow up protocol?

MO074: SGLT2 Inhibition Promotes Intrinsic Kidney Regeneration by Cells of the Renin Lineage

Abstract BACKGROUND AND AIMS With chronic kidney disease (CKD) prevalence rapidly increasing, the need for novel therapies is rising. Sodium glucose co-transporter-2 (SGLT2) inhibitors were originally developed to treat hyperglycemia in patients with type 2 diabetes mellitus. Clinical trials with the SGLT2 inhibitor empagliflozin revealed a marked attenuation of the slope of kidney function decline, also in patients with non-diabetic CKD. The exact mechanism of this kidney sparing effect still remains to be clarified. Interestingly, cells of renin lineage (CoRL), residing in the juxtaglomerular apparatus to regulate blood pressure and fluid balance, have been demonstrated to harbor a stem cell like potential. CoRL have the ability to replenish glomerular cell number by dedifferentiating, migrating and subsequently replacing various glomerular cell types in different kidney injury mouse models. Considering that empagliflozin treatment affects renin plasma levels and electrolyte balance in patients, we hypothesized that empagliflozin could have an effect on CoRL-induced glomerular regeneration. METHOD Experiments were performed in a Ren1cre; tdTomato lineage-trace mouse strain that expresses a tomato fluorescent label in all cells derived from renin lineage. Two kidney injury mouse models were applied; bilateral ischemia reperfusion injury (bIRI) and 5/6 nephrectomy (5/6NTx). Empagliflozin (10 mg/kg) was administered daily via oral gavage for 14 days. Subsequently, mice were sacrificed and kidneys were harvested for histological analysis. RESULTS In both the bIRI and 5/6NTx model, empagliflozin intake led to an increase (&amp;gt;2-fold) of CoRL found in the intraglomerular regions compared with vehicle control littermates. These CoRL seemed to selectively differentiate towards different glomerular cell types per model: bIRI combined with empagliflozin administration resulted in an increase of claudin- (10-fold) and integrin-α8- (1.5-fold) tomato double positive cells, suggesting favored differentiation from CoRL to respectively a parietal epithelial or mesangial cell type. In contrast, in the empagliflozin treated 5/6NTx model, an increase (1.5-fold) in tomato-podocyn double positive cells was observed, implying more restocking of glomerular podocytes by CoRL in this model. CONCLUSION SGLT2 inhibition by empagliflozin treatment leads to increased CoRL-mediated intrinsic regeneration potential and provides the kidney with different replenished cell types in different kidney disease models. Our findings demonstrate a novel mechanism via which SGLT2 inhibition might protect against kidney injury.

A0298 - Eleven years of experience with UTUC: Survival and renal function after kidney sparing surgery versus radical nephroureterectomy

A0298 - Eleven years of experience with UTUC: Survival and renal function after kidney sparing surgery versus radical nephroureterectomy

Use of formative evaluation surveying and tailored digital education to identify and address knowledge and competency gaps in upper tract urothelial carcinoma (UTUC) care.

307 Background: Upper tract urothelial carcinoma (UTUC) treatment poses a unique challenge for clinicians, due to the complexity in diagnosis, risk stratification, and a lack of treatment options, leading to a lower patient quality of life. However, recent advances in kidney sparing treatment options have created an opportunity for clinicians to integrate newer therapies into practice and improve function for UTUC patients. To address these needs, a serial educational initiative was designed for the uro-oncology team. Methods: A 2-part CE activity was launched in partnership with Large Urology Group Practice Association live-online in June and December, 2020, and remains on-demand through December, 2021 at UroCareLive.com and OMedLive.com. The first activity focused on diagnosis, risk stratification, and newer treatments. Formative evaluation was applied to obtain feedback from the 1st activity through an in-depth survey to clinician learners, the results of which were used to shape the content of the 2nd activity. Formative evaluation survey results revealed gaps in recognizing disease progression (48%), risk stratification (with difficulty obtaining tissue from upper urinary tract noted as the most common barrier; 57%), and experience with newer agents leading to a lack of their use in practice (62%). Only 23% rated their team’s training on patient education as “Very Good” or “Excellent.” Additionally, knowledge and competence questions were administered pre-, immediate post-activity, and at 2-months follow-up. Data from these questions were analyzed to determine engagement and remaining gaps. Results: To date, 788 clinicians participated in the activity. All 8 pre/post-test questions demonstrated statistically significant improvements in knowledge and competence concerning risk stratification, treatment applications, and adverse event management. At 2-mos. follow-up, 75% reported improved behavioral impact on clinical practice and 55% reported impact on patient experience and outcomes. Learners provided write-in examples detailing changes such as improved confidence and understanding of newer treatment options, patient experience, and increased use of kidney-sparing treatments including mitomycin gel. Conclusions: The activity was successful in demonstrating sustained knowledge advances in critical areas such as tumor categorizing and risk stratification, the use of emerging treatment options, and management of adverse events in practice. Use of formative evaluation surveying allowed identification of practice gaps and barriers to change, providing an opportunity for tailored education addressing these needs. Learners also reported strong post-activity improvements in clinical practice and patient outcomes, illustrating the importance of serial education for the uro-oncology team.

Treatment of Distal Upper Tract Urothelial Cancer with Distal Ureterectomy Preserves Renal Function without Increasing Local Recurrence Rate Compared with Radical Nephroureterectomy

Introduction: Kidney sparing surgery like endoscopic resection and distal ureterectomy has been recently proposed as alternative surgical options to manage distal Upper Tract Urothelial Cancer. This study aims to compare the surgical, oncological and functional outcomes of distal ureterectomy and Radical Nephroureterectomy for distal Upper Tract Urothelial Carcinoma. Methods and Material: Out of 57 patients with Upper Tract Urothelial Carcinoma treated surgically at a single institution between 2010 and 2016, nineteen patients had distal Upper Tract Urothelial Carcinoma. A retrospective review was performed on these 19 patients (11 Radical Nephroureterectomy and 8 distal ureterectomy). Radical Nephroureterectomy was performed using an open or laparoscopic approach (n= 4 and 7 respectively). All Distal Ureterectomy patients were performed via an open extra-peritoneal Gibson incision. Pelvic lymphadenectomy and Subsequent ureteroneocystostomy in the Distal Ureterectomy group was performed directly and was augmented by psoas hitch or using boari flap reconstruction. Demographic, clinical features and post-operative outcomes were compared between the Radical Nephroureterectomy and Distal Ureterectomy groups. Results: There was a trend towards shorter mean duration of surgery (238±34 vs. 286 ±90 min) and length of hospital stay (LOS) (7.6±2.8 vs. 17.3±20.7 days) in the Distal Ureterectomy group compared to the Radical Nephroureterectomy group (P=NS). Peri-operative Complication of Clavien grade 1-2 was seen in 4(33.33%) Radical Nephroureterectomy and 3 (37.5%) Distal Ureterectomy cases respectively. All patients had high grade Upper Tract Urothelial Carcinoma with equivalent pTNM staging in both groups with clear surgical margins. Immediate post-operative renal function improvement was statistically significant in the Distal Ureterectomy group (Radical Nephroureterectomy 2.27±5.93 vs 10.86±9.92 Distal Ureterectomy, p=0.034). Three out of 11 Radical Nephroureterectomy group patients required dialysis. Conclusions: Local recurrences were similar after Distal Ureterectomy and Radical Nephroureterectomy with equivalent pathological outcomes in distal Upper Tract Urothelial Carcinoma. There was a clear trend towards shorter hospital stay and better renal function preservation in favor of Distal Ureterectomy with fewer patients requiring dialysis.

PD64-10 ELEVEN YEARS OF EXPERIENCE WITH UPPER TRACT UROTHELIAL CARCINOMA: SURVIVAL AND RENAL FUNCTION AFTER KIDNEY SPARING SURGERY VERSUS RADICAL NEPHROURETERECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI (PD64)1 Sep 2021PD64-10 ELEVEN YEARS OF EXPERIENCE WITH UPPER TRACT UROTHELIAL CARCINOMA: SURVIVAL AND RENAL FUNCTION AFTER KIDNEY SPARING SURGERY VERSUS RADICAL NEPHROURETERECTOMY Nora Hendriks, Joyce Baard, Harrie P. Beerlage, Barbara M.A. Schout, Rob C.M. Pelger, Klara SG Doherty, and Guido M. Kamphuis Nora HendriksNora Hendriks More articles by this author , Joyce BaardJoyce Baard More articles by this author , Harrie P. BeerlageHarrie P. Beerlage More articles by this author , Barbara M.A. SchoutBarbara M.A. Schout More articles by this author , Rob C.M. PelgerRob C.M. Pelger More articles by this author , Klara SG DohertyKlara SG Doherty More articles by this author , and Guido M. KamphuisGuido M. Kamphuis More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002108.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The gold standard treatment for upper urinary tract urothelial carcinoma (UTUC) is by radical nephroureterectomy (RNU). Criteria to qualify for kidney sparing surgery (KSS) have become less strict in consecutive guidelines, thereby gaining a more prominent position. In this study we compare the oncological outcomes and renal function in patients with UTUC treated by KSS and RNU in a tertiary referral center. METHODS: In this retrospective cohort study, we included 174 adult patients with histopathological confirmed non-metastatic UTUC from 2010 through 2020 treated with either RNU or KSS (segmental ureter resection, ureterorenoscopy, percutaneous tumor resection). Risk stratification was based on the current EAU guidelines for UTUC. RESULTS: The RNU arm had a larger population (86.2%) of high risk tumors compared to the KSS arm (74.4%; p = 0.030). Recurrence Free Survival (RFS), Metastasis Free Survival (MFS), Overall Survival (OS) and Cancer Specific Survival (CSS) concerning KSS and RNU are presented in figure 1. Within the high risk KSS arm 73.2% did not have an imperative reason for choice of treatment. MFS (p = 0.004), CSS (p = 0.027) and OS (p = 0.033) were all significantly higher in the KSS arm when comparing high risk patients in both treatment groups (figure 2). There were no significant long-term differences in renal function, except for three months and one year after intervention (figure 3). CONCLUSIONS: Current guidelines indicate that high risk UTUC is best treated by RNU. In this study we conclude that MFS, CSS and OS are significantly higher in KSS in all tumors as well as in high risk tumors treated outside the scope of current guidelines. Source of Funding: Cure for Cancer © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1148-e1149 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nora Hendriks More articles by this author Joyce Baard More articles by this author Harrie P. Beerlage More articles by this author Barbara M.A. Schout More articles by this author Rob C.M. Pelger More articles by this author Klara SG Doherty More articles by this author Guido M. Kamphuis More articles by this author Expand All Advertisement Loading ...

P0785 - Novel classification for upper tract urothelial carcinoma to better risk-stratify patients eligible for kidney sparing strategies: an international collaborative study

P0785 - Novel classification for upper tract urothelial carcinoma to better risk-stratify patients eligible for kidney sparing strategies: an international collaborative study

Contemporary patterns of presentation, diagnostics and management of upper tract urothelial cancer in 101 centres: the Clinical Research Office of the Endourological Society Global upper tract urothelial carcinoma registry.

To assess patterns of presentation, diagnostics and treatment in patients with upper tract urothelial carcinoma (UTUC), a multicentre registry was launched. Clinical data of UTUC patients were prospectively collected over a 5-year period. Data from 2380 patients were included from 2014 to 2019 (101 centres in 29 countries). Patients were predominantly male (70.5%) and 53.3% were past or present smokers. The majority of patients (58.1%) were evaluated because of symptoms, mainly macroscopic hematuria. Computed tomography (CT) was the most common performed imaging modality (90.5%). A ureteroscopy (URS) was part of the diagnostic process in 1184 (49.7%) patients and 488 (20.5%) patients were treated endoscopically. In total, 1430 patients (60.1%) were treated by a radical nephroureterectomy, 59% without a prior diagnostic URS. Eighty-two patients (3.4%) underwent a segmental resection, 19 patients (0.8%) were treated by a percutaneous tumour resection. Our data is in line with the known epidemiologic characteristics of UTUC. CT imaging is the preferred imaging modality as also recommended by guidelines. Diagnostic URS gained a stronger position, however, in almost half of patients a definitive treatment decision was made without complete endoscopic information. Only one-third of patients with UTUC are currently treated with kidney sparing surgery.

THE FIRST CASE OF SIMULTANEOUS DECEASED DONOR LIVER AND KIDNEY TRANSPLANTATION IN AN HIV/HCV CO-INFECTED PATIENT WITH HEMOPHILIA IN JAPAN

We herein describe for the first case of simultaneous liver and kidney transplantation (SLK) in an HCV/HIV-coinfected patient with severe hemophilia in Japan. The patient was a 61-year-old Japanese man with HCV cirrhosis. He was diagnosed with haemophilia B at age 1 year. He was infected with HCV and HIV due to imported contaminated blood products. The patient’s liver disease was classified as Child-Pugh C, Model for End-Stage Liver Disease score 38. He had been on hemodialysis for 6 years, but both HIV RNA and HCV RNA had been undetectable after appropriate antiviral therapies. In September 2019, the patient underwent successful SLK. The donor was a man in 60’s deceased due to cerebral hemorrhage. Regular DDLT was performed using the piggyback technique with a full-sized liver graft. Cold ischemia time was 566 min, and the graft liver weighed 1,154 g. The graft kidney was transplanted extraperitoneally in the right iliac fossa. A total of 76 U of packed red cells and 100 U of fresh frozen plasma were infused during the 12-h procedure, which required packing and subsequent depaking procedure on day3. Also, the administration of clotting factor IX discontinued on day 3. The immunosuppressive regimen was based on i.v. induction with 2 mg/kg of basiliximab and 1g methylprednisolone and subsequent oral administration of mycophenolate mofetil and prednisolone, followed by low dose taclorimus after 1w for kidney sparing purpose. Steroid therapy was gradually discontinued at 3 months after SLK. The same pretransplantation antiretroviral therapy (ART; tenofovir and doltegravir) was introduced after 3 days when the CD4 cell count was more than 300/μl and HIV-RNA was within undetectable range. The postoperative course was uneventful without infectious complication, and the patient was transferred to referral hospital on day 90 and discharged home on day 111. Herein, we report the first case of SLK for HIV/HCV co-infected hemophilic patient in Japan. Strategic surgical planning and meticulous pre and post-transplant management of ART and clotting factors could lead to the success of SLK.

Re: Impact of Hospital Nephrectomy Volume on Intermediate- to Long-Term Survival in Renal Cell Carcinoma.

No AccessJournal of UrologyUrological Survey1 Nov 2020Re: Impact of Hospital Nephrectomy Volume on Intermediate- to Long-Term Survival in Renal Cell Carcinoma M. Pilar LagunaMD, PhD M. Pilar LagunaM. Pilar Laguna More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001259AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Re: Impact of Hospital Nephrectomy Volume on Intermediate- to Long-Term Survival in Renal Cell Carcinoma." The Journal of Urology, 204(5), pp. 1092–1093 Suggested Reading : Impact of surgical factors on robotic partial nephrectomy outcomes: comprehensive systematic review and meta-analysis. J Urol 2018; 200: 258. Link, Google Scholar : Trends in regionalization of inpatient care for urological malignancies, 1988 to 2002. J Urol 2007; 178: 2103. Link, Google Scholar : Hospital volume is a determinant of postoperative complications, blood transfusion and length of stay after radical or partial nephrectomy. J Urol 2012; 187: 405. Link, Google Scholar : Trends in renal surgery: robotic technology is associated with increased use of partial nephrectomy. J Urol 2013; 189: 1229. Link, Google Scholar : Volume-outcome relationships in the treatment of renal tumors. J Urol 2012; 187: 1984. Link, Google Scholar : National trends in the use of partial nephrectomy: a rising tide that has not lifted all boats. J Urol 2012; 187: 816. Link, Google Scholar : The impact of provider volume on outcomes from urological cancer therapy. J Urol 2005; 174: 432. Link, Google Scholar : Differential use of partial nephrectomy for intermediate and high complexity tumors may explain variability in reported utilization rates. J Urol 2013; 189: 2047. Link, Google Scholar : Contemporary trends in nephrectomy for renal cell carcinoma in the United States: results from a population based cohort. J Urol 2011; 186: 1779. Link, Google Scholar : Increasing use of kidney sparing approaches for localized renal tumors in a community based health system: impact on renal functional outcomes. J Urol 2011; 186: 1229. Link, Google Scholar : When partial nephrectomy is unsuccessful: understanding the reasons for conversion from robotic partial to radical nephrectomy at a tertiary referral center. J Urol 2017; 198: 30. Link, Google Scholar : Hospital surgical volume and associated postoperative complications of pediatric urological surgery in the United States. J Urol 2015; 194: 506. Link, Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 204Issue 5November 2020Page: 1092-1093 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information M. Pilar Laguna More articles by this author Expand All Advertisement PDF DownloadLoading ...

Ureteral location is associated with survival outcomes in upper tract urothelial carcinoma: A population-based analysis.

To evaluate the prognostic value of tumor location in patients with upper tract urothelial carcinoma. Within the Surveillance, Epidemiology and End Results Incidence Database, 6619 upper tract urothelial carcinoma cases were identified, including 3719 confined to the renal pelvis and 2971 to the ureter. Predictors of surgical technique (kidney sparing surgery versus radical nephroureterectomy), as well as 2- and 5-year cancer-specific survival and overall survival were evaluated. Median follow-up time was 29months (interquartile range 0-126months) for both groups. Multivariate logistic analysis showed tumor dimension as the only factor associated with radical nephroureterectomy (odds ratio 1.02; P<0.001). Ureteral 2- and 5-year overall survival were lower (log-rank P=0.001) compared with renal pelvis. When stratifying tumor location according to dimensions, a ureteral carcinoma >3cm was associated with the worst 2- and 5-year cancer-specific mortality (Pepe-Mori P<0.001), and overall survival (log-rank P<0.001). The 2- and 5-year cancer-specific mortality (Pepe-Mori P<0.001) and overall survival were the worst for ureteral ≥T3 tumors (log-rank P<0.001). The 2- and 5-year cancer-specific mortality (Pepe-Mori P<0.001) and overall survival (log-rank P<0.001) were the worst for ureteral gradeIII-IV cancers. Ureteral tumor location (subdistribution hazard ratio 1.18, P<0.001), tumor dimension ≥3 (subdistribution hazard ratio 1.25, P<0.001), T staging (T2-4 all P<0.001), grading (gradeIII subdistribution hazard ratio 2.20, P=0.001; gradeIV subdistribution hazard ratio 2.39, P<0.001) were found to be associated with higher cancer mortality. Ureteral tumor location in upper tract urothelial carcinoma seems to be associated with worse oncological outcomes, especially in the case of advanced disease. Although the type of surgical treatment does not seem to impact survival, surgeons should use caution in adopting a kidney-sparing surgery for patients with ureteral upper tract urothelial carcinoma.

Segmental ureterectomy vs. radical nephroureterectomy for ureteral carcinoma in patients with a preoperative glomerular filtration rate less than 90 ml/min/1.73 m2: A multicenter study

ObjectivesTo compare segmental ureterectomy (SU) and radical nephroureterectomy (RNU) in terms of overall survival (OS) and impact on postoperative renal function in patients treated for upper tract urothelial carcinoma (UTUC) of the ureter with preoperatively reduced estimated glomerular filtration rate (eGFR). Materials and methodsWe retrospectively collected the data of consecutive patients treated for UTUC, in 6 Italian tertiary referral centers, from 2003 to 2013, and analyzed those treated with RNU or SU for ureteral cancer and with a preoperative eGFR <90 ml/min/1.73m2. The primary outcome was to compare the postoperative eGFR variation and the OS according to the surgical technique chosen. ResultsOut of 521 patients with UTUC, 228 patients had preoperative reduced eGFR. Out of these patients, 93 had ureteral cancer and were included in the primary analyses – 67 (72.0%) treated with RNU and 26 (28.0%) with SU. Preoperative characteristics were similar in the 2 groups. The overall median follow-up period was 26.5 months. A nonsignificant postoperative eGFR decrease of 3.0 ml/min/1.73m2 was found overall (P = 0.094), with nonsignificant difference between the 2 groups (P = 0.735). A comparable 5-year OS was calculated for RNU and SU patients (P = 0.99). ConclusionsThe type of surgery (SU vs. RNU) has a low impact on postoperative renal function and OS in patients with ureteral cancer and preoperative eGFR <90 ml/min/1.73m2. The indications for kidney sparing surgery for UTUC should be based on the surgical and oncological risks in these patients.

MP82-19 ENDOSCOPIC MANAGEMENT OF UPPER TRACT UROTHELIAL CANCER - KIDNEY SPARING AT WHAT COST?

INTRODUCTION AND OBJECTIVE:Kidney sparing endoscopic treatment for elective indications is a relatively new paradigm in the management of upper tract urothelial cancer (UTUC). The aim of this study...

Quality of Care for Renal Masses: The Michigan Urological Surgery Improvement Collaborative-Kidney Mass: Identifying & Defining Necessary Evaluation & Therapy (MUSIC-KIDNEY).

We describe the establishment of the Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) to improve the quality of care that patients in Michigan receive for localized, 7 cm or smaller (T1) renal masses. The MUSIC-KIDNEY collaborative is comprised of 45 urologists from 8 group practices. From June 2017 to November 2018 surgeons collected data for 821 patients with newly diagnosed T1 renal masses. Goals are to reduce the overall burden of treatment for T1 renal masses specifically by avoiding treatment when a noninterventional approach is appropriate, reducing the treatment of benign renal masses, preventing radical nephrectomy when a kidney sparing approach is appropriate, and decreasing length of hospitalization and readmission rates. Median age at diagnosis was 66 years, 56.8% of patients were male and 83.8% were Caucasian. The patient populations differed across practice sites for age (p <0.001), tumor size (p=0.002), race (p <0.001), Charlson comorbidity index and insurance type (p <0.001). Tumor complexity was infrequently reported (35.1%). Initial management included surveillance/repeat imaging (45.1%), biopsy (15.4%), intervention (39.1%) and second opinion (0.6%). No treatment at initial presentation (0% to 74.5%) and nephron sparing treatment (0% to 100%) varied significantly among practices (p <0.001). Of 133 patients with T1 renal masses who underwent radical nephrectomy (39.8%) 53 had tumors smaller than 4 cm and/or surgical findings without malignancy. Readmission or emergency department visit within 30 days after renal surgery occurred in 7.6%. Initial findings of MUSIC-KIDNEY indicate practice level variation and several quality improvement opportunities. Focusing on these goals may optimize practice patterns and surgical outcomes across Michigan.