Nephron-sparing Management Research Articles

Outcomes of open versus robotic partial nephrectomy: a 20-year single institution experience.

Robotic assisted partial nephrectomy (RPN) has emerged in urologic practice for the management of appropriately sized renal masses. We provide a 20-year comparison of the outcomes of open partial nephrectomy (OPN) versus RPN for renal cell carcinoma (RCC) at our institution. An IRB-approved retrospective review was conducted of RCC patients at a single institution from 2000 to 2022 who underwent RPN or OPN. In addition to demographics, procedural details including ischemia and operative time were collected. Oncologic outcomes were evaluated through Kaplan-Meier statistical analysis to determine recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) analysis. 849 patients underwent RPN while 385 underwent OPN. 61% were male with average age of 58.8 ± 12.8years. Operative time was shorter in the open group (184 vs 200min, p = 0.002), as was ischemia time (16 vs 19min, p = 0.047). However, after 2012, RPN became more common than OPN with improving ischemia time. RPN patients had significantly improved RFS (HR 0.45, p = 0.0004) and OS (HR 0.51, p = 0.0016) when controlled for T-stage and margin status. More > pT1 masses were managed with OPN than RPN (11.2 vs 5.4%, p < 0.0001). At our institution, RPN had an increasing incidence with reduced ischemia time compared to OPN over the last 10years. While higher stage renal masses were more often managed with OPN, selective use of RPN does offer improved oncologic outcomes. Further investigation is needed to evaluate optimization of the selection of RPN versus OPN in the nephron-sparing management of renal masses.

V06-09 ROBOT-ASSISTED NEPHRON-SPARING MANAGEMENT OF URETERAL TUMORS: PATIENT-TAILORED APPROACH WITH DEMONSTRATION OF FOUR DIFFERENT TECHNIQUES

You have accessJournal of UrologyCME1 Apr 2023V06-09 ROBOT-ASSISTED NEPHRON-SPARING MANAGEMENT OF URETERAL TUMORS: PATIENT-TAILORED APPROACH WITH DEMONSTRATION OF FOUR DIFFERENT TECHNIQUES Sumit Saini, Timothy O'Rourke, and Ashok Hemal Sumit SainiSumit Saini More articles by this author , Timothy O'RourkeTimothy O'Rourke More articles by this author , and Ashok HemalAshok Hemal More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003274.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Need for renal function preservation may influence the decision to take a nephron sparing approach of segmental ureterectomy for localized ureteral tumors, as an alternative to radical nephroureterectomy. In this video we demonstrate four different individualized surgical techniques tailored according to patient’s disease. METHODS: All the surgeries were performed by single surgeon (AKH) using da Vinci (Si/Xi) robotic surgical system. For distal ureteral tumors, distal ureterectomy with bladder cuff excision/partial cystectomy with pelvic lymph node dissection (PLND) and uretero-neo-cystostomy was performed in 11 patients. Proximal ureteral tumors were addressed with segmental ureterectomy and uretero-ureterostomy in 5 patients and another patient underwent augmented anastomotic ureteroplasty using free circumferential ileal patch. Regardless of the surgical approach adopted, complete preoperative evaluation was carried out with cross sectional imaging and other investigations (renogram, retrograde pyelogram & nephrostogram) as indicated. These procedures were considered in carefully selected patients with unifocal disease associated with medical co-morbidities, advancing age, and compromised renal function. Intraoperative fluoroscopy guided navigation and/or molecular imaging using indocyanine green (intraluminal or intravascular) are also helpful. RESULTS: In this video, we have demonstrated four such techniques, including our novel approach of augmented anastomotic ureteroplasty with free circumferential ileal patch to bridge a significant defect following segmental ureterectomy. We have also highlighted our novel technique of intra-corporeal JJ stent placement. No intra or post operative complications were noted, and all the surgical margins were negative. JJ Stents was removed in about 4 weeks post-operatively. CONCLUSIONS: Robot-assisted patient-tailored approach for ureteral tumors may be effectively employed in appropriately selected patients of ureteral tumors with excision and end to end anastomosis, augmented anastomosis or uretero-neo-cystotomy with psoas hitch as an alternative to radical nephroureterectomy to salvage the ipsilateral kidney. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e511 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sumit Saini More articles by this author Timothy O'Rourke More articles by this author Ashok Hemal More articles by this author Expand All Advertisement PDF downloadLoading ...

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

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

Impact of age on functional decline following radical nephrectomy: Analysis of the International Marker Consortium for Renal Cancer (INMARC).

664 Background: Radical nephrectomy (RN) is a mainstay of management of localized renal cancer &gt;4 cm. RN is associated with renal functional decline, however impact of age on functional decline is unclear. We investigated impact of age on post RN function, focusing on decline to moderate and severe chronic kidney disease (CKD). Methods: This was a retrospective analysis of patients who underwent RN. Patients were stratified by age (&lt;50, 50-70 and &gt;70 years). Primary outcome was development of denovo CKD-S 3b [estimated glomerular filtration rate (eGFR) &lt;45 mL/min/1.73m2)]. Secondary outcomes included denovo CKD-S 3a (eGFR&lt;60) and denovo CKD-S 4 (eGFR&lt;30). Multivariable logistic regression analysis (MVA) was utilized to identify risk factors for renal functional decline. Linear regression was utilized to identify risk factors for increasing DeGFR. Kaplan-Meier analysis (KMA) was utilized to evaluate functional outcomes for different age groups Results: We analyzed 2436 patients (&lt;50 years, n=513; 50-70 years, n=1344; &gt;70, n=579; median follow-up 31.9 months). On MVA, increasing age was an independent risk factor for CKD-S 3a (HR=3.4-9.4, p&lt;0.001), CKD-S 3b (HR=3.4-7.7, p&lt;0.001), and denovo CKD-S 4 (HR=1.96, p=0.027). On linear-regression analysis, increasing age was significantly correlated with increased delta eGFR (β=-0.212, p&lt;0.001). KMA Comparing &lt;50, 50-70 and &gt;70 demonstrated age-associated declines in 5-year freedom from denovo CKD-S 3a (73.9%; 50-70 53.7%; and &gt;70 37.06%, respectively, p&lt;0.001), denovo CKD-S 3b (92.7%; 71.8%; and 55.5%, p&lt;0.001) and denovo CKD-S 4 (93.7%; 89.8%; and &gt;70 81.2%, p&lt;0.001). Conclusions: Increasing age is a risk factor for progressive and clinically significant renal functional decline after RN. Prioritization for nephron-sparing management may be considered when indicated and oncologically safe and feasible in elderly patients to reduce potential risk of sequelae of functional decline. [Table: see text]

Percutaneous Thermal Ablation for Renal Tumors in Patients with Birt-Hogg-Dubé Syndrome.

Simple SummaryPercutaneous thermal ablation (TA) could be a safe and efficient nephron-sparing treatment for treating renal cell carcinoma (RCCs) associated with Birt–Hogg–Dubé (BHD) syndrome, a rare hereditary condition at greater risk of repeated treatments, even in the case of advanced chronic kidney disease, and should be systematically discussed as a treatment option. Indications for nephron-sparing management of these tumors in BHD patients depends on many factors, including size, number, and location of the tumor(s) in each kidney, patient surgical history, and renal function. The role of the tumor board including radiologists, interventional radiologists, urologists, and oncologists is essential.BHD syndrome is characterized by an increased risk of bilateral and multifocal renal cell carcinoma (RCCs), but is rarely metastatic. Our report aims to analyze the outcome of patients with BHD syndrome who underwent percutaneous thermal ablation (TA). The present report included six BHD syndrome patients (five men) with a mean age of 66 ± 11 (SD) years who had a proven germline FLCN gene mutation and underwent TA for a renal tumor. Nineteen renal tumors (median two tumors per patient; range: 1–3), including seven chromophobe RCCs, five clear-cell RCCs, four papillary RCCs, two clear-cell papillary RCC, and one hybrid oncocytic/chromophobe tumor were treated in 14 ablation sessions. The mean size of the tumors was 21 ± 11 (SD) mm (median: 20 mm; interquartile range (IQR): 14–25 mm) for a mean volume of 7 ± 11 (SD) mL (median: 3; IQR: 1–5 mL). Technical success was achieved in all ablation sessions (primary success rate, 100%). The procedure was well tolerated under conscious sedation with no significant Clavien–Dindo complication (grade 2, 3, 4). All patients were alive with no distant metastasis during a median follow-up period of 74 months (range: 33–83 months). No local tumor progression was observed. The mean decrease in estimated glomerular filtration rate was 8 mL/min/1.73 m2. No patients required dialysis or renal transplantation. In this case series, percutaneous TA appeared as a safe and efficient nephron-sparing treatment for treating RCCs associated with BHD syndrome, even in the case of advanced chronic kidney disease.

Impact of age on functional decline following radical nephrectomy: Analysis of the International Marker Consortium for Renal Cancer (INMARC).

395 Background: Radical nephrectomy (RN) is a mainstay of management of localized renal cancer larger than 4 cm in size. RN is associated with renal functional decline, however impact of age on functional decline is unclear. We investigated impact of age on post RN function, focusing on decline to moderate and severe chronic kidney disease (CKD). Methods: This was a retrospective analysis of the International Marker Consortium for Renal Cancer (INMARC) registry of patients who underwent RN. Primary outcome was development of de novo CKD stage IIIB [estimated glomerular filtration rate (eGFR)&lt;45 mL/min/1.73m2). Secondary outcomes included de novo CKD stage III (eGFR&lt;60) and CKD Stage IV (eGFR&gt;30). Patients clinical characteristics were stratified by age groups (&lt;50, 50-70 and &gt;70 years old). Multivariable logistic regression analysis (MVA) was utilized to identify risk factors with renal functional decline to different CKD stages. Kaplan-Meier analysis (KMA) was utilized to evaluate functional outcomes with respect to the different age groups. Results: Overall, 2,436 patients were analyzed (≤50 years, n=513; 50-70 years, n=1,344; &gt;70, n=579; median follow up 31.9 months). On MVA, increasing age was independently associated with increased risk of development of CKD Stage IIIb [compared to ≤50 years (referent), 50-70 years, OR 3.35, p&lt;0.001 and &gt;70 years OR 7.7, p&lt;0.001]. In addition, increasing BMI (OR 1.029, p=0.002), coronary artery disease (OR 1.70, p=0.01), diabetes mellitus (OR 1.37, p=0.029) and African American race (OR 1.6, p=0.01) were independent risk factors for CKD stage IIIb. Increasing age was also independently associated with an increased risk of development of CKD Stage III [compared to ≤50 years (referent), 50-70 years, OR 3.4 p&lt;0.001 and &gt;70 years OR 9.4, p&lt;0.001]. Increasing BMI (OR 1.032, p=0.002) and coronary artery disease (OR 1.87, p=0.015) were also risk factors for CKD stage III. Age &gt;70 years was independently associated with increased risk of development of CKD Stage IV [OR 1.96, p=0.027]. In addition, male (OR 1.49, p= 0.036), increasing BMI (OR 1.03, p=0.003), diabetes mellitus (OR 2.69, p &lt;0.001), and African American race (OR 2.02, p=0.002) were risk factors for CKD stage IV. Kaplan-Meier Analyses demonstrated age associated declines in 5 year freedom from CKD Stage III (≤50 years 73.9%, 50-70 years 53.7%, and &gt;70 years 37.06%, p&lt;0.001), CKD Stage IIIb (age ≤50 years 92.7%, 50-70 years 71.8%, and &gt;70 years 55.5%, p&lt;0.001) and CKD Stage IV (age ≤50 years 93.7%, 50-70 years 89.8%, and &gt;70 years 81.2%, p&lt; 0.001). Conclusions: Increasing age is an independent risk factor for progressive and clinically significant renal functional decline after radical nephrectomy. Prioritization for nephron sparing management should be considered whenever safe and feasible in elderly patients to reduce potential risk of sequelae of functional decline.

Nephron-sparing management of upper tract urothelial carcinoma.

Urothelial carcinoma of the upper urinary tract is uncommon and presents unique challenges for diagnosis and management. Nephroureterectomy has been the preferred management option, but it is associated with significant morbidity. Nephron-sparing treatments are a valuable alternative and provide similar efficacy in select cases. A PubMed literature review was performed in English language publications using the following search terms: urothelial carcinoma, upper tract, nephron-sparing, intraluminal and systemic therapy. Contemporary papers published within the last 10 years were primarily included. Where encountered, systematic reviews and meta-analyses were given priority, as were randomized controlled trials for newer treatments. Core guidelines were referenced and citations reviewed for inclusion. A summary of epidemiological data, clinical diagnosis, staging, and treatments focusing on nephron-sparing approaches to upper tract urothelial carcinoma (UTUC) are outlined. Nephron-sparing management strategies are viable options to consider in patients with favorable features of UTUC. Adjunctive therapies are being investigated but the data remains mixed. Protocol variability and dosage differences limit statistical interpretation. New mechanisms to improve treatment dwell times in the upper tracts are being designed with promising preliminary results. Studies investigating systemic therapies are ongoing but implications for nephron-sparing management are uncertain. Nephron-sparing management is an acceptable treatment modality best suited for favorable disease. More work is needed to determine if intraluminal and/or systemic therapies can further optimize treatment outcomes beyond resection alone.

Nephroureterectomy vs. segmental ureterectomy of clinically localized, high-grade, urothelial carcinoma of the ureter: Practice patterns and outcomes

BackgroundNephroureterectomy (NU) remains the gold-standard for upper-tract urothelial carcinoma (UTUC). However, nephron-sparing management (NSM), specifically segmental ureterectomy (SU) for urothelial tumors distal to the renal pelvis may offer decreased risk of renal insufficiency and equivalent cancer control. ObjectivesTo identify patient-specific and facility-related factors that are associated with the selection of SU vs. NU for patients with clinically localized, high-grade, ureteral UTUC. Design, setting, participantsWe searched the National Cancer Database between 2004 and 2015 for patients with high-grade, clinically localized, primary ureteral UTUC managed by either NU or SU. Outcome measurements and statistical analysisUnivariate and multivariate analysis was performed to assess patient, disease-specific, facility and treatment-related factors associated with SU vs. NU. Since surgical approach was only indexed after 2010, separate multivariable logistic regressions were performed including and excluding surgical approach in order to capture patients treated between 2004 and 2009. Survival analysis utilized Kaplan-Meier methods and Cox proportional hazards regression. Results and limitationsMultivariate analysis including surgical approach demonstrated that among other factors, higher clinical stage (P = 0.034), larger tumor size (P < 0.001), the addition of neoadjuvant chemotherapy (P = 0.002), and the utilization of minimally invasive surgery (P < 0.05) decreased the likelihood of patients receiving SU. In this same cohort, institutions with larger facility volumes (P = 0.038) and performing intraoperative lymph node dissection (P < 0.001) were associated with a higher probability of SU. Excluding surgical approach, once again more advanced clinical stage (P = 0.005), larger tumor size (P < 0.001), and neoadjuvant chemotherapy (P = 0.003) decreased the probability of patients receiving SU, while increasing age (P = 0.049) and intraoperative lymph node dissection (P < 0.001) were more closely associated with SU compared to NU. No differences were noted in pathological T stage (P > 0.05), 30-day readmission (P = 0.7), 30-day mortality (P = 0.09), and 90-day mortality (P = 0.157) on multivariate analysis between SU and NU. Additionally, no significant differences were seen in median overall survival between patients receiving SU or NU (53 vs. 50 months; P = 0.143). ConclusionsComparable outcomes suggest segmental ureterectomy for high-grade ureteral UTUC is appropriate in well-selected patients. Practice patterns appear consistent with guideline recommendations (decreased tumor size and lower clinical stage favor SU), but treatment disparities may exist based on a multitude of patient, pathologic- and facility-related factors. Improved dissemination of knowledge regarding practice patterns and outcomes of SU for UTUC of the ureter has the potential to improve delivery of NSM in appropriate patients. Patient summaryIn this study, we examined factors associated with different surgical procedures for cancer of the ureter. We found that smaller tumor sizes, a less advanced clinical stage, intraoperative lymph dissection higher facility volumes tended to favor kidney-sparing treatment, while survival outcomes appear comparable to renal extirpation.

MP68-09 DISPARITIES IN SURVIVAL OUTCOMES IN AFRICAN AMERICANS IN RENAL CELL CARCINOMA

INTRODUCTION AND OBJECTIVE: African-Americans have an increased incidence of renal cortical tumor subtypes of lower oncological potential in the setting of lower risk disease when compared to other ethno-racial groups. On the other hand, survival outcomes are similar. We investigated the impact of African-American race on functional outcomes and non-cancer mortality. METHODS: Multi-institutional (Emory, TMDU, UCSD, SLU) retrospective analysis of patients with localized renal cell carcinoma (AJCC clinical stage 1-3 RCC) who underwent partial or radical nephrectomy between 1998-2018. The cohort was divided into African-American and Non-African American subgroups for descriptive analyses. Patients were analyzed for demographics, clinical parameters, and post-surgical outcomes. Primary outcome was non-cancer mortality (NCM). Secondary outcome was eGFR decline. Multivariable logistic regression (MVA) was used to elucidate predictive factors for NCM and de novo eGFR<45 and <30 ml/min/1.73m2. Kaplan Meier Analysis (KMA) was performed to analyze 5-year freedom from non-cancer mortality. RESULTS: 3751 patients who received either partial or radical nephrectomy for renal masses were grouped into African American (AA, n=602) and Non-African American (NAA, n=3149) sub-groups for analysis. No difference was noted between groups with respect to mean tumor size (p=0.166). Risk factors for development of de novo eGFR<45 included increasing age (OR 1.059, p<0.001), AA race (OR 1.47, p=0.047, diabetes mellitus (OR 1.84, p<0.001), and radical nephrectomy (OR 3.28, p<0.001). MVA for worsened NCM demonstrated AA race (OR 1.4, p=0.013), increasing age (OR 1.05, p<0.001), and post-operative eGFR<45 (OR 2.8, p<0.001) to be independent risk factors. KMA revealed a significant difference between African-Americans and Non-African Americans in terms of 5 year NCM (AA 81% vs. NAA 88%, p<0.001). CONCLUSIONS: African Americans undergoing renal surgery for RCC appear to have poorer NCM than non-African American patients. The cause of this disparity is likely multi-faceted but may be associated with functional decline. Nephron-sparing management when feasible and appropriate should be considered in African-Americans presenting with renal cortical tumors.Source of Funding: Stephen Weissman Kidney Cancer Research Fund

Impact of oncological versus nononcological on survival outcomes in African Americans with renal cell carcinoma.

749 Background: African-Americans have an increased incidence of renal tumors of lower oncological potential when compared to other ethno-racial groups. Yet, survival outcomes are similar. We investigated the impact of African-American race on overall survival, oncological and functional outcomes, and non-cancer mortality. Methods: Multi-institutional (Emory, TMDU, UCSD) retrospective analysis of patients who underwent partial or radical nephrectomy between 1998-2018. Primary outcome was overall survival (OS). Secondary outcomes were non-cancer mortality (NCM), recurrence free survival (RFS), and eGFR decline. Multivariable logistic regression (MVA) was used to analyze OS, NCM, and RFS, and estimated glomerular filtration rate (eGFR)&lt;45 and &lt;30 ml/min/1.73m2. Results: 3632 patients were grouped into African American (AA, n=531) and Non-African American (NAA, n=3101). No difference was noted between groups with respect to mean tumor size (p=0.31). NAA had a higher proportion of metastases at presentation (9.9% vs. 7.0%, p=0.04). AA race was an independent risk factor for functional decline to de novo eGFR &lt;45 (OR=1.43, p=0.04) and de novo eGFR&lt;30 (OR 2.01, p&lt;0.001). MVA for worsened NCM demonstrated AA race (OR=1.63, p=0.02), increasing age (OR=1.05, p&lt;0.001), male sex (OR=1.56, p=0.01), and hypertension (OR=1.73, p=0.001) to be independent risk factors. Significant factors on MVA for worsened OS included increasing age (OR=1.03, p&lt;0.001), radical nephrectomy (OR=1.47, p=0.01), increasing tumor size (OR=1.11, p&lt;0.001), hypertension (OR=2.63, p&lt;0.001), high tumor grade (OR=1.97, p&lt;0.001), and post-operative eGFR &lt;45 (OR=1.50, p=0.01). MVA for worsening RFS demonstrated high tumor grade (OR=2.04, p&lt;0.001) and increasing clinical tumor size (OR=1.15, p&lt;0.001) to be independent factors. Conclusions: African Americans undergoing surgical management for RCC appear to have similar OS and RFS, but poorer NCM than non-African American patients. The cause of these disparities is multi-faceted but likely is associated with functional decline. Nephron-sparing management when feasible and appropriate should be considered in African-Americans presenting with renal cortical tumors.

V08-09 IMAGE-GUIDED ROBOT-ASSISTED PARTIAL NEPHRECTOMY (IGRAPN): COMBINING 3 IMAGING TECHNIQUES TO PERFORM AN ANATOMICAL ZERO ISCHEMIA HEMI-NEPHRECTOMY

INTRODUCTION AND OBJECTIVES:Nephron sparing management of big renal masses is a challenging procedure due to the difficulties in optimal preservation of healthy parenchyma, maintaining an acceptabl...

Disparities in survival outcomes in African Americans in renal cell carcinoma: Impact of oncological versus nononcological factors.

595 Background: African-Americans have increased incidences of renal cortical tumor subtypes of lower oncological potential in the setting of lower risk disease when compared to other ethno-racial groups. However, survival outcomes are similar. We investigated the impact of African-American race on overall survival, oncological outcomes, functional outcomes, and non-cancer mortality. Methods: Multi-institutional retrospective analysis of patients who underwent partial or radical nephrectomy between 1998-2018. Primary outcome was overall survival (OS). Secondary outcomes included non-cancer mortality (NCM), recurrence free survival (RFS), and estimated glomerular filtration rate (eGFR) decline. Multivariable logistic regression (MVA) were used to elucidate predictive factors for OS, NCM, and RFS, and eGFR &lt;45 and &lt;30 ml/min/1.73m2. Results: 3,088 patients were divided into African American (AA, n=353) and Non-African American (NAA, n=2735) sub-groups. No difference was noted between groups with respect to mean tumor size (p=0.211) or metastases presence (p=0.846). African-American race was an independent risk factor for functional decline to eGFR&lt;45 (OR 4.43, p&lt;0.001) and eGFR&lt;30 (OR 5.15, p&lt;0.001). MVA for worsened NCM demonstrated African-American race (OR=1.72, p=0.042), increasing age (OR=1.03, p=0.001), radical nephrectomy (OR=2.98, p&lt;0.001), and increasing tumor size (OR=1.26, p&lt;0.001) to be independent risk factors. MVA for worsened OS included increasing age (OR=1.04, p&lt;0.001), tumor size (OR=1.182, p&lt;0.001), clear cell histology (OR=1.62, p&lt;0.001), high tumor grade (OR=2.12, p&lt;0.001), and post-operative eGFR &lt;45 (OR=2.12, p&lt;0.001). MVA for worsening RFS demonstrated high tumor grade (OR=2.38, p&lt;0.001) and increasing clinical tumor size (OR=1.152, p&lt;0.001) to be independent factors. Conclusions: African Americans undergoing renal surgery for RCC appear to have similar OS and RFS, but poorer NCM than non-African American patients. The cause of these disparities is multi-faceted and likely associated with functional decline. Nephron-sparing management should be considered in African-Americans presenting with renal cortical tumors.

VE20 - Robot assisted nephron sparing management of high renal score renal tumour. Case report and tertiary oncologic center experience

VE20 - Robot assisted nephron sparing management of high renal score renal tumour. Case report and tertiary oncologic center experience

Nephron-sparing management of Xanthogranulomatous pyelonephritis presenting as spontaneous renal hemorrhage: a case report and literature review

BackgroundXanthogranulomatous pyelonephritis (XGP) is an uncommon infectious disease of the kidney known to mimic other renal maladies. A rare presentation of this uncommon disease is spontaneous renal hemorrhage (SRH).Case presentationWe report a case of XGP in a 58 year old woman who presented with abdominal pain, hematuria, and radiating left flank pain. CT scan was felt to be consistent with perirenal hemorrhage abutting a fat-containing renal mass. The patient was eventually taken to surgery for left partial nephrectomy. Pathology report returned as XGP, and the patient has no complications from this disease process at 8 month follow up.ConclusionOur search of the literature shows XGP presenting as SRH to be a rare clinical entity. Furthermore, this is the first such case managed with a nephron-sparing approach. The “great imitator” XGP should be added to the differential for patients presenting with spontaneous renal hemorrhage.

Nephron-sparing management (distal ureterectomy with reimplantation of ureter) for carcinoma of distal ureter: A single-center experience

ObjectiveRadical nephroureterectomy with bladder-cuff excision has been the traditional treatment for upper tract urothelial carcinoma because of its high rate of recurrence. However, given the morbidity of nephrectomy and the risk of developing chronic kidney disease or dialysis-dependent renal failure, the nephron-sparing approach may be preferable in selected patients. Materials and methodsA total of 118 patients who received unilateral distal ureterectomy with reimplantation at a single center in Taiwan were included, using surgical code numbers, from March 2006 to December 2014. A total of 82 patients were excluded due to nonmalignancy and 17 due to concomitant bladder cancer. Finally, 19 patients with primary, solitary, unilateral ureter lesions and confirmed to have ureter malignancy (urothelial carcinoma, n=18; squamous cell carcinoma, n=1) were included. ResultsOf the 19 patients (13 males and 6 females) included, the mean age was 69.3±10.7 years. Tumor pathological staging was Tis (n=1), Ta (n=3), T1 (n=2), T2 (n=6), and T3 (n=5). Histopathology grading was low grade (n=3) and high grade (n=13). No local recurrence was noted; nine patients had bladder recurrence (47.4%), three had distant metastasis (15.8%), and two had progression and finally underwent radical nephroureterectomy (10.5%). The mean time to bladder recurrence was 12.4 months (3–24 months); the mean follow-up time was 28.1 months (1–90 months). The 5-year overall survival rate was 73.7% (14/19); four patients were lost to follow-up, and one patient expired. The mean 5-year progression-free survival was 67.74%. The mean preoperative creatinine level was 1.61 mg/dL, and at 12 months after operation it was 1.56 mg/dL (p=0.95). ConclusionIn selected patients, distal ureterectomy with reimplantation, in our experience, is a feasible option for distal ureter tumor. Favorable postoperative outcomes with a low local recurrence rate, a low rate of progression to nephroureterectomy, and renal function preservation may prove the value of this modality and should be taken into consideration in suitable patients.

A Case for Nephron Sparing Surgery in the Management of Upper Tract Urothelial Carcinoma.

Upper tract urothelial carcinoma (UTUC) is rare and its management presents many challenges. Outside of distal ureterectomy for select cases, management has been primarily radical nephroureterectomy. Endoscopic nephron sparing management (NSM) is recognized to have some role in UTUC treatment; however, it is yet to gain firm footing in the treatment algorithm. In this review, we discuss the benefits of NSM with regards to oncologic outcomes, renal function preservation, and cost savings. Finally, we propose recognition of endoscopic NSM as a first-line treatment in selected patients with low risk disease.

Upper tract urothelial carcinoma: Paradigm shift towards nephron sparing management.

Upper tract urothelial carcinoma (UTUC) is relatively rare compared to urothelial carcinoma of the lower tract, comprising only 5%-10% of all urothelial cancers. Although both entities share histologic properties, UTUC tends to be more invasive at diagnosis and portend a worse prognosis, with a 5 year overall mortality of 23%. To date, the gold standard management of UTUC has been radical nephroureterectomy (RNU), with nephron sparing techniques reserved for solitary kidneys or cases where the patient could not tolerate radical surgery. Limited data from these series, as well as select series where nephron-sparing endoscopic management has been offered to a broader patient base, suggest that minimally invasive, nephron sparing techniques can offer comparable oncologic and survival outcomes to RNU in appropriately selected patients. We review the current literature on the topic and discuss long term outcomes and sequelae of the gold standard treatment, RNU. We also discuss the oncologic outcomes of minimally invasive, endoscopic management of UTUC. Our goal is to provide the reader a comprehensive overview of the current state of the field in order to inform and guide their treatment decisions.

Nephron-sparing management (distal ureterectomy with reimplantation of ureter) for carcinoma of distal ureter: A single center experience

Nephron-sparing management (distal ureterectomy with reimplantation of ureter) for carcinoma of distal ureter: A single center experience

Outcomes of partial nephrectomy for clinical T1b and T2 renal tumors.

To review current status of partial nephrectomy for treatment of T1b and T2 renal mass, focusing oncological and renal functional outcomes reported in the last 18 months, and to understand the emerging role of minimally invasive surgery (MIS) techniques in nephron-sparing management of T1b/T2 tumors. With recent long-term oncological equivalence to radical nephrectomy and renal functional benefit, partial nephrectomy is becoming an alternate standard to radical nephrectomy in the management of T1b tumors. The role of partial nephrectomy in nonelective treatment of T2 tumors is more controversial; however, recent publication of two large North American series have added to other contemporary work that suggests oncologic equivalence and renal functional benefit compared to radical nephrectomy in select patients. Emerging data demonstrate feasibility of MIS for increasing the proportion of T1b/T2 tumors; however, recent trends analyses demonstrate that the majority of T1b/T2 partial nephrectomy are still carried out by open surgery, and concerns continue about prolonged ischemic times and risk of bleeding in various MIS settings. Management of T1b and T2 renal masses is transforming with adoption of partial nephrectomy as a safe and feasible surgical option with comparable oncological and improved renal function outcomes compared to radical nephrectomy. MIS techniques play an expanding, though still limited, role, and more robust prospective data is requisite before drawing overarching conclusions.

Current evidence on lasers in laparoscopy: partial nephrectomy.

Laser-assisted partial nephrectomy (PN) can benefit from the excellent coagulative properties of lasers to provide a bloodless tumor excision without the necessity for renal artery clamping. In this review, we aim to determine the current clinical implementation of laser assistance during laparoscopic nephron-sparing surgery. An extensive literature evaluation on laser-assisted PN was performed. Experimental work on animals and review articles were excluded. Current literature regarding laser-assisted PN is scarce. Available data consist mostly of small cohorts providing low level of evidence. Even though initial studies with currently available laser modalities demonstrated promising results, several drawbacks in each technique need to be addressed before being widely accepted as a standard care. Experience with laser-assisted laparoscopic PN is steadily increasing and uniformly documenting favorable results. As urologist became more familiar with laser technology by its implementation in other clinical entities and with the increasing interest in nephron-sparing management of renal tumors, the use of laser assistance during PN should be expected to play a major role in future.