Nephrectomy Database Research Articles

Paraneoplastic Resolution Holds Prognostic Utility in Patients with Metastatic Renal Cell Carcinoma.

Background/Objectives: The presence of paraneoplastic syndromes (PNS) in patients with renal cell carcinoma (RCC) is associated with worse survival; however, little is known about whether resolution of PNS after intervention has any prognostic value. We sought to determine if resolution of PNS by one year after cytoreductive nephrectomy was significantly associated with improved overall survival (OS) and cancer-specific survival (CSS). Methods: We retrospectively reviewed a prospectively maintained nephrectomy database for patients with any histology metastatic RCC (mRCC) who underwent nephrectomy between 2000 and 2022. Patients with the necessary laboratory studies available within 90 days before and by one year after surgery were included for study. PNS resolution was defined as an abnormal value compared to established laboratory cutoffs by one year after surgery. Multiple PNS in one patient was allowed, and resolution of each PNS was measured separately. OS and CSS were assessed using Kaplan-Meier curves and Cox proportional hazards models. Results: A total of 253 patients met inclusion criteria. A total of 177 patients (70.0%) met criteria for at least one PNS resolution by one year. Five-year OS and CSS rates were 15.7% and 36.2% for no PNS resolved, 24.5% and 31.6% for 1 PNS resolved, and 43.0% and 58.2% for ≥2 PNS resolved, respectively (p < 0.001). On multivariable analysis, no PNS resolution was associated with worse OS (HR 2.75, p < 0.001) and CSS (HR 2.62, p < 0.001) compared to ≥2 PNS resolved. Conclusions: Resolution of preoperative PNS abnormalities by one year following surgery is associated with improved OS and CSS in patients with mRCC.

Paraneoplastic Syndrome Prevalence and Survival in Racially-Diverse Cohort With Renal Cell Carcinoma

IntroductionThe prevalence of preoperative paraneoplastic syndromes (PNS) in renal cell carcinoma (RCC) is poorly understood. Many laboratory abnormalities representative of PNS have demonstrated prognostic value when incorporated into predictive survival models in RCC. We sought to characterize the relationship between baseline prevalence of PNS with overall survival (OS) and cancer-specific survival (CSS) in RCC patients following nephrectomy. MethodsOur prospectively maintained nephrectomy database was retrospectively reviewed for any stage, major histology RCC patients that underwent surgery from 2000 to 2022. Baseline laboratory values within 90 days (closest used) were required. Presence of PNS was defined according to established laboratory cutoffs. Kaplan-Meier curves estimated survival rates, and multivariable Cox proportional hazards models examined the association between PNS with OS and CSS following nephrectomy. Results2599 patients were included with listed staging: 1494 Stage I; 180 Stage II; 616 Stage III; 306 Stage IV. Proportion of patients presenting with >1 PNS significantly increased from stage I (31.3%) to stage IV (74.2%) RCC (P < .001). Elevated C-reactive protein was the most prevalent PNS (45.4%). On multivariable analysis, the presence of >1 PNS was associated with higher risk of all-cause (HR 2.09; P < .001) and cancer-specific mortality (HR 2.55; P < .001). The 10-year OS estimates as reported: 65.2% (no PNS), 52.3% (1 PNS), 36.6% (>1 PNS); and 10-year CSS estimates: 88.3% (no PNS), 79.3% (1 PNS), 61.6% (>1 PNS). DiscussionIncreased prevalence of PNS in major histology RCC was associated with a significant increase in the risk of all-cause and cancer-specific mortality even when accounting for patient and disease characteristics.

Perioperative and functional outcomes following robot-assisted partial nephrectomy: Descriptive analysis of Indian study group on partial nephrectomy database.

There is an unmet need for high-quality data for Robot-assisted partial nephrectomy (RAPN) in the Indian population. Indian study group on partial nephrectomy (ISGPN) is a consortium of Indian centers contributing to the partial nephrectomy (PN) database. The current study is a descriptive analysis of perioperative and functional outcomes following RAPN. For this study, the retrospective ISGPN database was reviewed, which included patients who underwent RAPN for renal masses at 14 centers across India from September 2010 to September 2022. Demographic, clinical, radiological, perioperative, and functional data were collected and analyzed. Ethics approval was obtained from each of the participating centers. In this study, 782 patients were included, and 69.7% were male. The median age was 53 years (interquartile range [IQR 44-62]), median operative time was 180 min (IQR 133-240), median estimated blood loss was 100 mL (IQR 50-200), mean warm ischemia time was 22.7 min and positive surgical margin rates were 2.5%. The complication rate was 16.2%, and most of them were of minor grade. Trifecta and pentafecta outcomes were attained in 61.4% and 60% of patients, respectively. This is the largest Indian multi-centric study using the Indian Robotic PN Collaborative database to evaluate the outcomes of robot-assisted PN, and has proven its safety and efficacy in the management of renal masses.

Linear Muscle Segmentation for Metastatic Renal Cell Carcinoma: Changes in Clinic-Friendly Estimation Predict Survival Following Cytoreductive Nephrectomy

IntroductionBaseline sarcopenia and postoperative changes in muscle mass are independently associated with overall survival (OS) in patients with metastatic renal cell carcinoma (mRCC) undergoing cytoreductive nephrectomy (CN). Here we examine the relationships between preoperative (baseline), postoperative changes in muscle quantity, and survival outcomes following CN as determined by linear segmentation, a clinic-friendly tool that rapidly estimates muscle mass. Materials and MethodsOur nephrectomy database was reviewed for patients with metastatic disease who underwent CN for RCC. Linear segmentation of the bilateral psoas/paraspinal muscles was completed for baseline imaging within 60 days of surgery and imaging 30 to 365 days postoperatively. Kruskal-Wallis for numerical and Fisher's exact test for categorical variables were used to test for differences between groups according to percent change in linear muscle index (LMI, cm2/m2). Multivariable Cox proportional hazards models evaluated associations between LMI percent change and cancer-specific (CSM) and all-cause mortality (ACM). Kaplan Meier curves estimated cancer-specific (CSS) and overall survival (OS). ResultsFrom 2004-2020, 205 patients were included of whom 52 demonstrated stable LMI (25.4%; LMI change < 5% [0Δ]), 60 increase (29.3%; LMI +5% [+Δ]), and 92 decrease (44.9%; LMI -5% [-Δ]). Median time from baseline imaging to surgery was 18 days, and time from surgery to postoperative imaging was 133 days. Median CSS and OS were highest among patients with 0Δ LMI (CSS: 133.6 [0Δ] vs. 61.9 [+Δ] vs. 37.4 [-Δ] months; P = .0018 || OS: 67.2 [0Δ] vs. 54.8 [+Δ] vs. 29.5 [-Δ] months; P = .0007). Stable LMI was a protective factor for CSM (HR 0.48; P = .024) and ACM (HR 0.59; P = .040) on multivariable analysis. DiscussionChange in muscle mass after CN, as measured by the linear muscle segmentation technique, is independently associated with OS and CSS in patients following CN. Of note, lack of change was associated with longer survival.

Angiomyolipoma of the kidney-Clinicopathological analysis of 52 cases.

The renal angiomyolipoma (AML) is a benign tumor characteristically composed of fat, smooth muscle tissue, and vessels. We collected AMLs from our nephrectomy database, reclassified them according to their histological appearance, recorded the demographic, clinical, and pathological parameters, and compared them with oncocytoma (RO) and renal cell carcinoma (RCC). Immunohistochemistry was ordered in 41 cases. In 2224 nephrectomies, we found 52 AMLs with a 53mm median size. The mean age was 52.76. Forty-eight tumors were sporadic, while four were hereditary. The revision resulted in 31 classic, 13 leiomyoma-like, five lipoma-like, two epithelioid, and one AML with epithelial cysts. SMA was diffusely positive, except for the epithelioid type, while MelanA harbored stronger expression than HMB45. AML was more frequent in females and appeared ten and 7years earlier than RO and RCC, respectively. The follow-up time was 7.42years, and neither tumor-related death nor relapse occurred. AML is rare in nephrectomies and develops primarily in females in their 50s with an average size of 50-60mm at the surgery. The histological appearance in order of frequency is classic, leiomyoma-like, lipoma-like, epithelioid, and cystic. The MelanA, HMB45, and SMA immunohistochemistry can support the light-microscopic findings.

A comparison of surgical practice and operative outcomes between retroperitoneal and transperitoneal laparoscopic nephrectomies – 6 years of data from the BAUS Nephrectomy database

Objectives: While the choice of surgical approach for laparoscopic nephrectomy is broadly split between transperitoneal and retroperitoneal options, the evidence for the impact of this decision on perioperative outcomes is built on relatively small volume data, with often inconsistent findings and conclusions. We aimed to assess the impact of operative approach on perioperative outcomes for laparoscopic radical, partial and simple nephrectomy and nephroureterectomy through analysis of the British Association of Urological Surgeons (BAUS) Nephrectomy database. Patients and methods: All patients added to the BAUS Nephrectomy database with laparoscopic surgery between 2012 and 2017 inclusively were included and subdivided by operation and surgical approach. Preoperative patient and tumour characteristics, as well as intraoperative and post-operative short-term outcomes, were assessed. Results: Overall, 26,682 operations were documented over the review window (81.6% transperitoneal). Small increases in blood loss ( p = 0.001), transfusion rate ( p = 0.02) and operative length ( p = 0.01) were seen for transperitoneal radical nephrectomies and longer hospital stays seen for retroperitoneal procedures (radical nephrectomy p = 0.00l; partial nephrectomy p = 0.04). Retroperitoneal procedures were associated with increased rates of conversion for simple nephrectomy ( p = 0.02), nephroureterectomy ( p = 0.03) and most notably partial nephrectomy (10.5% versus 4.4%; p = 0.001). No further variation in intraoperative complications, post-operative complications, tumour margin positivity rates, unintended ITU admission, or likelihood of death was identified related to surgical approach. Conclusion: Observed variations in perioperative outcomes were generally modest in nature, and little ground is seen to support a change in operative technique for those committed to one approach. A caveat to this exists with open conversion for retroperitoneal partial nephrectomies and requires careful consideration of patient selection by the individual surgeon. Level of evidence: 4

Contemporary standards in UK nephrectomy practice: Analysis of the British Association of Urological Surgeons Complex Operations Reports, 2016–2018

Objective: To analyse the 2016–2018 British Association of Urological Surgeons (BAUS) Complex Operations Reports nephrectomy database, providing a comprehensive description of modern nephrectomy practice. Patients and Methods: Analysis of 2016–2018 data held on the BAUS Complex Operations Reports nephrectomy database was performed for 21,366 patients in England. Data are reported on patient, disease, operation and outcome variables. Results: Using Hospital Episode Statistics (HES) as a comparator, the database captured an estimated 88% of nephrectomies. Benign nephrectomies (BNs) accounted for 11%, 51% were radical nephrectomies (RNs), 14% were nephroureterectomies (NUs) and 22% were partial nephrectomies (PNs). Of the 2399 BNs, 10% were performed for stone disease, 9% for allograft donation and 9% for infective pathology. Aetiology was not specified further than non-functioning kidney in 51% of cases; 80% of cases adopted minimally invasive surgery (MIS). Histology was benign in 96% of cases. Of 10,843 RNs performed, 77% were performed using MIS. Final histology was renal cell carcinoma in 87% of cases and benign histology confirmed in 9% of cases. Of 3038 NUs performed, 88% were performed using MIS. Histology confirmed malignancy in 94% of cases with transitional cell carcinoma accounting for 82% of cases overall. Of 4708 PNs performed, 74% were performed using MIS; 85% of cases were performed for T1 disease; 16% of cases overall returned benign histology. Across the cohort, 30-day mortality was 0.36%. Transfusion rates were 3.3%, 6.1%, 3.3% and 2.0% for BNs, RNs, NUs and PNs, respectively. In malignant disease, positive surgical margins were present in 0.7% of RNs, 1.2% of NUs and 7.3% of PNs. Conclusions: The BAUS nephrectomy dataset provides a real-world description of nephrectomy practice across England, enabling surgeons to compare their practice against a national average. This dataset allows surgeons to share data with patients enhancing informed consent and facilitating shared-decision making. Overall, MIS is widespread, and early mortality after nephrectomy is low. Level of evidence: 2B

MP59-17 PSEUDOANEURYSM OF THE RENAL ARTERY FOLLOWING ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY: SINGLE-CENTER ANALYSIS OF PREDICTIVE FACTORS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy V (MP59)1 Sep 2021MP59-17 PSEUDOANEURYSM OF THE RENAL ARTERY FOLLOWING ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY: SINGLE-CENTER ANALYSIS OF PREDICTIVE FACTORS Yu Pin Huang, Hsiao Jen Chung, I. Shen Huang, Tzu Ping Lin, Eric Y. H. Huang, Shing Hwa Lu, Allen W. H. Chiu, and William J. S. Huang Yu Pin HuangYu Pin Huang More articles by this author , Hsiao Jen ChungHsiao Jen Chung More articles by this author , I. Shen HuangI. Shen Huang More articles by this author , Tzu Ping LinTzu Ping Lin More articles by this author , Eric Y. H. HuangEric Y. H. Huang More articles by this author , Shing Hwa LuShing Hwa Lu More articles by this author , Allen W. H. ChiuAllen W. H. Chiu More articles by this author , and William J. S. HuangWilliam J. S. Huang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002094.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal artery pseudoaneurysm (RAP) after partial nephrectomy is uncommon but a potential life-threatening complication. The aim of the study is to investigate the incidence of RAP after RaPN and identify the predictive factors. METHODS: We reviewed our institutional robotic-assisted partial nephrectomy (RaPN) database conducted from December 2009 to August 2020. Renal artery pseudoaneurysm (RAP) was diagnosed by computed tomography angiography (CTA) for patients who were suspected of having RAP clinically. Patients who had RAP after RaPN were compared with other patients who did not have RAP. Patients’ demographic data, tumors’ characteristics, and operative outcomes were evaluated. Statistical analyses were used to identify the predictive factors of RAP after RaPN. RESULTS: A total of 473 patients who underwent RaPN was reviewed, and 10 patients (2.1%) developed RAP median of 10 days (interquartile range: 6 - 14.5 days) after surgery. Most those patients experienced gross hematuria and were diagnosed by CTA. No patients had recurrent RAP during follow-up after treatment (8 patients underwent embolization, 1 patient underwent exploratory laparotomy, and 1 patient underwent observation). No difference was found in tumor size, total preoperative aspects and dimensions used for an anatomical (PADUA) scores, total operative time, warm ischemia time, blood loss, intraoperative blood transfusion rates between patients who had RAP versus controls. However, higher total higher R.E.N.A.L Nephrometry Score (median 9.0 versus 8.0, p=0.038), more renal sinus involvement in PADUA score (median 2.0 versus 1.0, p=0.045) and longer postoperative hospital stays (median 6.0 days versus 5.0 days, p=0.014) were noted in the patients who had developed RAP postoperatively. Besides, more proportion of patients who had 3 points N score (nearness to renal sinus or collecting system) in R.E.N.A.L score in RAP group, which reached statistically significance (p=0.042). CONCLUSIONS: The incidence of RAP is rare (2.1%). The occurrence of RAP is associated with higher R.E.N.A.L Score, and longer postoperative hospital stays. In nephrometry analysis, nearness of tumor to sinus or renal sinus involvement is associated with occurrence of RAP. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1037-e1037 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yu Pin Huang More articles by this author Hsiao Jen Chung More articles by this author I. Shen Huang More articles by this author Tzu Ping Lin More articles by this author Eric Y. H. Huang More articles by this author Shing Hwa Lu More articles by this author Allen W. H. Chiu More articles by this author William J. S. Huang More articles by this author Expand All Advertisement Loading ...

How “simple” is laparoscopic transperitoneal simple nephrectomy for a novice surgeon

IntroductionTo assess the perioperative outcome of laparoscopic transperitoneal simple nephrectomy and to see how difficult it is for a novice laparoscopic surgeon.Materials and methodsThe laparoscopic transperitoneal simple nephrectomy database between July 2012 and February 2019 was analyzed. The data of the first 50 cases performed by each of the three surgeons (group 1, 2, and 3) were divided into two subgroups- A: cases 1-25, and B: cases 26-50. Data analyzed included operative time, blood loss, conversion to open, the number of cases taken to reach a steady perioperative outcome and complications.ResultsBaseline characteristics of patients including the aetiology of the non-functioning/poorly functioning kidney were similar between the three groups. Though the mean operative time differs between the three surgeons, it decreased significantly till 20-25 cases and then remained steady thereafter among all three surgeons. The presence of hilar or perinephric inflammation secondary to pyonephrosis or stone disease was the factor associated with longer operative time and the need for conversion to open. The grade 3 or higher post-operative complications were similar between the three groups. ConclusionOperative time was the significant perioperative factor that became steady after approximately 20 cases of laparoscopic transperitoneal simple nephrectomy but not the other factors like blood transfusion rate or grade III complications.

Incisional Lumbodorsal Hernias Following Retroperitoneal Robotic Partial Nephrectomies for Small Renal Masses at a High-Volume Tertiary Referral Center.

Introduction: Herein we evaluate the incidence of incisional lumbodorsal hernia (ILDH) after retroperitoneal robotic partial nephrectomy (RRPN) and associated patient-specific and tumor-specific risk factors. Furthermore, we aim to evaluate the role of routine lumbodorsal fascial closure for the prevention of ILDH. Methodology: This is a retrospective review of our robotic partial nephrectomy database of all RRPNs performed at Washington University School of Medicine from 2000 to 2020. Postoperative imaging was reviewed for evidence of ILDH. A clinically significant hernia was defined as the protrusion of visceral organ(s) through the lumbodorsal fascia. Patient and tumor characteristics, and fascial closure techniques were analyzed to determine predictors of ILDH. Results: In total, 150 patients underwent RRPN between 2007 and 2020 with an average follow-up of 4.9 (1-37) months. Twelve (8%) ILDHs were identified. Ten (6.7%) patients had herniated retroperitoneal fat whereas 2 (1.3%) patients had herniated colon. All were asymptomatic and managed conservatively. On matched cohort comparison, patients with ILDH had larger tumors than patients without an incisional hernia (3.9 cm vs 2.8 cm, p = 0.029). In general, patient factors were no different between patients with and without ILDH. However, coronary artery disease (CAD) was more prevalent in patients with ILDH (33.3% vs 10.9%, p = 0.028). Patients with ILDH were more likely to have a port site extended for specimen extraction (66.7% vs 38.2%, p = 0.069). Lumbodorsal fascial closure and type of suture material were not associated with prevention of ILDH (p = 0.545, p = 0.637). Conclusion: The radiographic incidence of lumbar incisional hernias after RRPN without routine fascial closure of the extraction incision was 8%. All were asymptomatic and did not require surgical repair. Larger tumor size and CAD were associated with ILDH.

MP21-05 CHANGING PATTERNS OF INTRAOPERATIVE ANALGESIA AND THE EFFECT OF INTRAOPERATIVE OPIOIDS AND ADJUNCT ANALGESICS ON CANCER RECURRENCE AFTER NEPHRECTOMY: A ROLE FOR ONCO-ANESTHESIA?

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy III (MP21)1 Apr 2020MP21-05 CHANGING PATTERNS OF INTRAOPERATIVE ANALGESIA AND THE EFFECT OF INTRAOPERATIVE OPIOIDS AND ADJUNCT ANALGESICS ON CANCER RECURRENCE AFTER NEPHRECTOMY: A ROLE FOR ONCO-ANESTHESIA? Andrew W Silagy, Stanley Weng*, Margaret L Hannum, Roy Mano, Kyrollis Attalla, Renzo DiNatale, Julian Marcon, Kay See Tan, Jonathan A Coleman, Paul Russo, Gregory W Fischer, Patrick J McCormick, A Ari Hakimi, and Joshua S Mincer Andrew W SilagyAndrew W Silagy More articles by this author , Stanley Weng*Stanley Weng* More articles by this author , Margaret L HannumMargaret L Hannum More articles by this author , Roy ManoRoy Mano More articles by this author , Kyrollis AttallaKyrollis Attalla More articles by this author , Renzo DiNataleRenzo DiNatale More articles by this author , Julian MarconJulian Marcon More articles by this author , Kay See TanKay See Tan More articles by this author , Jonathan A ColemanJonathan A Coleman More articles by this author , Paul RussoPaul Russo More articles by this author , Gregory W FischerGregory W Fischer More articles by this author , Patrick J McCormickPatrick J McCormick More articles by this author , A Ari HakimiA Ari Hakimi More articles by this author , and Joshua S MincerJoshua S Mincer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000854.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intraoperative analgesics may impact oncological outcomes in various malignancies, however this association has not been tested in kidney cancer. in the enhanced recovery era, anesthesiologists utilize a range of analgesics which target different cell receptors and potentially also have systemic and direct effects on tumors. Therefore, we aimed to determine whether there is an association between types of anesthesia and oncological outcomes in kidney cancer. METHODS: We reviewed our institution’s prospectively maintained nephrectomy database for patients with malignant renal histology treated with surgery. Total intraoperative morphine milligram equivalents (MME) of opioids and the administration of ketamine and dexmedetomidine were extrapolated from anesthetic charts. We performed univariate and multivariate Cox regression (adjusting for patient age, TNM stage, histology and tumor size) to look for associations between analgesics and recurrence-free survival (RFS) for localized patients, and cancer-specific survival (CSS) and overall survival (OS) for the entire cohort. RESULTS: The cohort consisted of 2775 localized and 206 metastatic patients, with a median age of 60 (52, 68). There were 183 patients and 340 patients who received ketamine and dexmedetomidine, respectively; these patients received less intraoperative opioids on average (50 vs 59 vs 74 MME, p<0.001), particularly since 2015 (Figure 1). There were 152 recurrences and 286 deaths during follow up. An increase of 10 MME was associated with adverse RFS on univariate and multivariate analysis (HR 1.04, 1.01 – 1.07, p=0.018). A 10 MME increase was associated with worse CSS (HR 1.09, 1.06 – 1.13, p<0.001) and OS (HR 1.07, 1.04 – 1.09, p<0.001) on univariate analysis, but this was not significant on multivariate analysis. Ketamine administration was associated with improved RFS on multivariate analysis (HR 0.40, 0.16 – 1.00, p=0.050), but not CSS or OS. Dexmedetomidine was not associated with RFS, CSS or OS. CONCLUSIONS: Intraoperative ketamine and reduced opioid administration appear to improve oncological outcomes following kidney surgery. This signal warrants additional mechanistic and prospective clinical studies. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e319-e319 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew W Silagy More articles by this author Stanley Weng* More articles by this author Margaret L Hannum More articles by this author Roy Mano More articles by this author Kyrollis Attalla More articles by this author Renzo DiNatale More articles by this author Julian Marcon More articles by this author Kay See Tan More articles by this author Jonathan A Coleman More articles by this author Paul Russo More articles by this author Gregory W Fischer More articles by this author Patrick J McCormick More articles by this author A Ari Hakimi More articles by this author Joshua S Mincer More articles by this author Expand All Advertisement PDF downloadLoading ...

The Association Between Small Primary Tumor Size and Prognosis in Metastatic Renal Cell Carcinoma: Insights from Two Independent Cohorts of Patients Who Underwent Cytoreductive Nephrectomy

BackgroundOne of the main challenges in the management of renal cell carcinoma (RCC) is risk-stratifying patients who present with metastatic disease. Tumor size is an important predictor of survival in the localized setting; however, this feature has not been explored fully in patients presenting with M1 RCC. ObjectiveTo assess the impact of tumor size on survival in patients with metastatic RCC who underwent cytoreductive nephrectomy (CN). Design, setting, and participantsWe queried the Memorial Sloan Kettering (MSK) nephrectomy database for patients who presented with M1 disease and underwent CN between 1989 and 2016 (n=304). Primary tumor size was obtained from pathology reports. Data from the International Metastatic Database Consortium (IMDC) were used for validation purposes (n=778). Outcome measurements and statistical analysisOverall survival (OS) estimates were computed using the Kaplan-Meier method. Cox regressions were used to test the association between tumor size and OS in univariate and multivariable analyses. Tumors ≤4cm were compared with larger masses. Secondary analyses were performed to assess the robustness of these findings. Results and limitationsClear cell tumors ≤4cm were significantly associated with improved OS in both the MSK (hazard ratio [HR]: 0.35, 0.17–0.72, p= 0.004) and IMDC (HR 0.54, 0.36–0.83, p= 0.004) cohorts. The association was observed even after adjusting for known prognostic factors (HR 0.40, 0.14–1.14, p= 0.09 and HR: 0.54, 0.33–0.90, p= 0.02 in the MSK and IMDC cohorts, respectively). Limitations of this study include the absence of patients who were considered poor surgical candidates as well as potential selection bias. ConclusionsThe primary tumor size ≤4cm was independently associated with improved OS in patients with metastatic clear cell RCC who underwent CN. Additionally, the association between primary size and survival was found to be nonlinear. These findings suggest that there is a group of small metastatic RCCs that can convey a better overall prognosis. The potential role of primary tumor size when risk stratifying patients with M1 RCC should be explored further to determine its utility during clinical decision making. Patient summaryWe evaluated the impact of small tumor size on prognosis in patients with metastatic kidney cancer who undergo removal of the primary tumor. Very small masses (≤4cm) were associated with better prognosis in patients with clear cell tumors.

Feasibility of adopting retroperitoneal robotic partial nephrectomy after extensive transperitoneal experience.

Adoption of robotic retroperitoneal surgery has lagged behind robotic surgery adoption in general due to unique challenges of access and anatomy. We evaluated our initial results with robotic retroperitoneal robotic partial nephrectomy (RRPN) after transitioning from exclusively transperitoneal robotic partial nephrectomy (TRPN) to evaluate safety and any identifiable learning curve. We evaluated our single-surgeon (RA) prospective partial nephrectomy database since adopting RRPN routinely for posterior tumors in 2017. The surgeon had previously performed 410 partial nephrectomies by this time. Outcomes were compared after the initial 30 RRPN. Of 137 patients since adopting RRPN, two attempted RRPN were converted to TRPN without complications due to morbid obesity affecting access, and 30 RRPN were completed (107 TRPN). There were no statistically significant differences in demographics, mean tumor size, or RENAL score between groups. Mean blood loss was lower in RRPN (53mL vs 99mL, P < 0.05), but there were no transfusions in either group. There was no difference in mean operative (127.8min vs 141.2min, P = 0.06) or ischemia time (11.1min vs 10.8min, P = 0.98). There were no positive margins in either group. Mean length of stay was lower in RRPN due to more same-day discharges (0.7 vs 0.9days). There were no 90-day Clavien III-V complications. One RRPN patient was readmitted POD#8 overnight for hypoxia, and one visited the emergency room POD#7 for persistent pain. All three TRPN complications were managed as outpatients. Successful adoption of RRPN can be achieved readily after experience with TRPN. Outcomes were immediately comparable without any identifiable learning curve.

"At-risk" kidney: How surgical factors influence renal functional preservation after partial nephrectomy.

To investigate the influence of surgical modifiable factors on chronic kidney disease upstaging in a contemporary cohort of patients with normal and "at-risk" kidneys undergoing partial nephrectomy. We reviewed 778 consecutive patients with (n=634)/without (n=144) chronic kidney disease or risk factors for chronic kidney disease in our institutional partial nephrectomy database. Chronic kidney disease upstaging was assessed using glomerular filtration rate measurements preoperatively and at 3-12months postoperatively. Using a multivariate logistic regression, baseline clinicodemographic factors, and the operative measurements of excisional volume loss and warm and cold ischemia time on rates of chronic kidney disease upstaging were determined. Marginal effects were used to analyze the impact of ischemia time and generate interaction curves. Chronic kidney disease/risk factors for chronic kidney disease had equivalent rates of chronic kidney disease upstaging as the healthy kidney cohort (31.5% vs 38.2%, P=0.15). Of the entire cohort, 2.8% were upstaged to stageIV-V chronic kidney disease. Multivariate analysis found a significant association between chronic kidney disease upstaging and excisional volume loss in both cohorts (no chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.63, P=0.04; chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.42, P=0.001). Only in the chronic kidney disease/risk factors for chronic kidney disease cohort, there was an association between ischemia type/duration and chronic kidney disease upstaging (odds ratio 1.04, P=0.04). Warm ischemia began to predict an increased risk of chronic kidney disease upstaging at 17.6min, which became statistically significant at 49min. Chronic kidney disease upstaging is common after partial nephrectomy. Although volume loss unequivocally affects rates of upstaging irrespective of baseline renal function, warm ischemia time disproportionately influences "at-risk" kidneys. Therefore, strong consideration should be given to minimizing volume loss and using cold ischemia when extended clamp times are anticipated in "at-risk" kidneys.

Predictors of positive surgical margins in patients undergoing partial nephrectomy: A large single-center experience.

To identify preoperative factors that predict positive surgical margins in partial nephrectomy. Using our institutional partial nephrectomy database, we investigated the patients who underwent partial nephrectomy for malignant tumors between January 2011 and December 2015. Patient, tumor, surgeon characteristics were compared by surgical margin status. Multivariable logistic regression was used to identify independent predictors of positive surgical margins. A total of 1025 cases were available for analysis, of which 65 and 960 had positive and negative surgical margins, respectively. On univariate analysis, positive margins were associated with older age (64.3 vs. 59.6, p<0.01), history of prior ipsilateral kidney surgery (13.8% vs. 5.6%, p<0.01), lower preoperative eGFR (74.7 mL/min/1.73 m2 vs. 81.2 mL/min/1.73 m2, p=0.01), high tumor complexity (31.8% vs. 19.0%, p=0.03), hilar tumor location (23.1% vs. 12.5%, p=0.01), and lower surgeon volume (p<0.01). Robotic versus open approach was not associated with the risk of positive margins (p=0.79). On multivariable analysis, lower preoperative eGFR, p=0.01), hilar tumor location (p=0.01), and lower surgeon volume (p<0.01) were found to be independent predictors of positive margins. In our large institutional series of partial nephrectomy cases, patient, tumor, and surgeon factors influence the risk of positive margins. Of these, surgeon volume is the single most important predictor of surgical margin status, indicating that optimal oncological outcomes are best achieved by high-volume surgeons.

Validation of a novel preoperative inflammatory score in localized, clear cell RCC.

697 Background: A previously created and analyzed composite renal cell carcinoma (RCC) inflammatory score composed of preoperative serum markers was found to be a significant and independent predictor of overall survival in RCC with accuracy at least as good as other established prognostic tools. The aim of our study was therefore to validate the prognostic significance of this novel score in a new, independent cohort of localized clear cell RCC patients. Methods: A new cohort was randomly selected out of our nephrectomy database from a group of patients with localized clear cell RCC, who underwent nephrectomy from March 2007 to June 2017. Biomarker composition, cutoffs, and calculations of the RCC inflammatory score were accurately recreated from the previous publication. The final score was the sum of points accrued for each biomarker, ranging from 0-10, followed by stratification into baseline (0), low (1-3), intermediate (4-6), and high-risk (7-10) groups. ROC and chi-square analysis were performed to compare the prognostic ability of this novel score to SSIGN, UISS, mGPS, and Leibovich Scores. Impact on overall survival was analyzed with multivariate logistic regression analysis. Results: 252 patients were included in the study. On multivariate analysis, after adjusting for confounding variables, a “high-risk” RCC inflammatory score proved to be an independent and significant predictor of increased mortality (HR = 9.65, 95%CI 1.06-87.79, p = 0.044). At median follow up time, only 45% of high-risk score patients were alive compared with 89-98% of all other patients. Chi-square analysis of c-indices for the RCC inflammatory score and current prognostic scores revealed no statistically significant difference in prognostication of overall survival. Conclusions: Concordant with our previous data, this study reveals that a high-risk RCC inflammatory score is an independent and significant predictor of overall survival in localized clear cell RCC with comparable accuracy to accepted prognostic tools. Distinct from the original study, the high-risk group displayed an even greater association than previously shown, but the intermediate-risk group was no longer significantly different from baseline risk.

Significance of the nonneoplastic renal parenchymal findings in robotic partial nephrectomy series.

To describe the pathological characteristics of the peritumoral non-neoplastic renal parenchyma (NNRP) and to investigate their impact on long-term renal function after partial nephrectomy. In our institutional robotic partial nephrectomy database, we identified 394 cases with pathological assessment of the NNRP and long-term postoperative renal functional follow-up. The NNRP was classified as normal (healthy renal parenchyma) or abnormal, based on the presence of arteriosclerosis, glomerulosclerosis, interstitial fibrosis, interstitial inflammation, and/or tubulopapillary hyperplasia. The primary outcome was a ≥ 20% decline in estimated glomerular filtration rate (eGFR) at 6 and 12months after surgery. Multivariable analysis was used to assess the association between NNRP and eGFR decline, with adjustment for demographic, clinical, and tumor factors. Overall, 250 (63.5%) pathological specimens had abnormal NNRP features. The most prevalent isolated benign pathological feature was glomerulosclerosis (18.0%), followed by arteriosclerosis (16.8%), interstitial inflammation (12.4%), interstitial fibrosis (1.2%), and tubulopapillary hyperplasia (0.4%). The abnormal NNRP group was associated with older age (p = .01), preoperative diabetes mellitus (p = .01), and preoperative hypertension (p = .01). The preoperative eGFR was significantly lower in the abnormal NNRP group (p = .01). NNRP abnormalities were not significantly associated with eGFR decline at either 6 or 12months. The only independent predictor of eGFR decline was warm ischemia time (p = .01), and this association was only observed at 12months. NNRP features are associated with preoperative comorbidities and lower baseline eGFR; however, they are not independent predictors of long-term renal functional preservation after partial nephrectomy.

Factors associated with acutely elevated serum creatinine following radical tumour nephrectomy: the Correlates of Kidney Dysfunction-Tumour Nephrectomy Database study.

BackgroundTo identify factors associated with acutely elevated serum creatinine (SCr) within 7 days of radical tumour nephrectomy.MethodsThe study population consisted of 130 consecutive patients managed for renal tumours. The primary outcome was acute kidney injury (AKI) (defined as SCr increase ≥50% above baseline), assessed using multivariable logistic regression analysis. The secondary outcome was SCr percentage increase, assessed using multivariable linear regression analysis.ResultsFollowing nephrectomy, the mean percentage increase in SCr in the first week was 55%±29%, and 77 (59%) patients experienced AKI. Independent predictors of AKI post-nephrectomy were male gender [adjusted odds ratio (OR): 2.67; 95% confidence interval (95% CI): 1.01, 6.93], urine albumin-creatinine ratio (OR: 0.66; 95% CI: 0.47, 0.91), preoperative estimated glomerular filtration rate (eGFR) (OR: 1.03; 95% CI: 1.00, 1.05), laparoscopic nephrectomy (OR: 3.02; 95% CI: 1.00, 9.12), and non-clear cell renal cell carcinoma (RCC) (OR: 2.93; 95% CI: 1.04, 8.29). Independent predictors of a SCr increase were male gender (β: 12.0; 95% CI: 2.69, 21.3), urine albumin-creatinine ratio (β: –3.36; 95% CI: –6.55, –0.16), preoperative eGFR (β: 0.38; 95% CI: 0.10, 0.66), laparoscopic nephrectomy (β: 12.7; 95% CI: 1.05, 24.3) and obesity (β: 9.94, 95% CI: 0.61, 19.3).ConclusionsMale gender, albuminuria, eGFR and laparoscopic nephrectomy independently associated with acutely elevated serum creatinine following radical tumour nephrectomy.

The Synergistic Influence of Ischemic Time and Surgical Precision on Acute Kidney Injury After Robotic Partial Nephrectomy

To examine the dynamic and potentially synergistic influence of warm ischemia time (WIT) and excisional volume loss (EVL) on predicted rates of postpartial acute kidney injury (AKI) across a range of tumor complexities, and to investigate whether these modifiable variables sensitize the kidney to each other's damaging influence. We retrospectively reviewed 1245 patients between 2006 and 2016 with bilateral kidneys and enhancing renal masses in our single-institution robotic partial nephrectomy (PN) database. EVL was calculated as the difference between specimen and tumor volume based on pathologic measurements. Multivariate logistic regressions, followed by marginal effects, were run to examine the interaction of ischemia type, EVL, and radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line score on rates of AKI. We found a significant interaction effect of WIT and log EVL on predicted AKI (P < .001). Each doubling of EVL caused a 4.03% and 8.46% increased probability of AKI for WIT of <25 and >25 minutes, respectively. At an EVL of >5.5 cm3, prolonged WIT had statistically greater odds of causing AKI. These predicted effects on AKI were amplified for increasing radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line scores (P < .001). Although the adverse functional effects of WIT and parenchymal volume loss during PN have previously been described in isolation, our findings suggest that their influence on AKI is synergistic, especially in complex tumors. As such, additional attention should be given to limiting warm ischemia and maximizing surgical precision to avoid a "double hit" on postoperative renal function.

Is Robotic Partial Nephrectomy Safe for T3a Renal Cell Carcinoma? Experience of a High-Volume Center.

To compare the oncological and functional outcomes of robotic partial nephrectomy (RPN) with radical nephrectomy (RN) in renal-cell carcinoma (RCC) cases with pT3a staging. A retrospective analysis of our IRB-approved nephrectomy database from 2005 to 2015 was performed. RPN and RN cases with confirmed RCC and pT3a staging were matched. Preoperative variables, functional, and oncological outcomes were compared between the groups, as well as Kaplan-Meier estimated overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). A multivariable Cox proportional hazards regression model for overall mortality rate was generated to evaluate hazard ratios (HRs) of potential risk factors. Seventy patients with pT3a tumors composed each group. Preoperative variables were comparable between groups. The median follow-up time for the cohort was 20 (9-38) months and the renal function preservation was higher in the RPN group (86% vs 70%; p < 0.001). The estimated 3 years of OS (90% vs 84%; p = 0.42), CSS (94% vs 95%; p = 0.78), and RFS (95% vs. 100%; p = 0.06) were similar between RPN and RN groups, respectively. On multivariable Cox regression model, the presence of ≥2 aggressive tumor features was the only factor associated with increased risk of overall mortality rate (HR 4.01 95% confidence interval [1.13, 14.27)]; p = 0.03). Patients with localized pT3a RCC treated with RPN had similar short-term oncological and better renal functional outcomes compared with similar cases treated by RN. In the minimally invasive robotic surgery era, renal masses suspicious for pathological T3a disease should not be a deterring factor for performing nephron-sparing surgery when technically feasible by skilled surgeons.