Partial Nephrectomy In Patients Research Articles

V5-13 THE USE OF ARGON BEAM COAGULATION DURING ROBOTIC PARTIAL NEPHRECTOMY IN AN ANIMAL MODEL

You have accessJournal of UrologyRenal Oncology1 Apr 2015V5-13 THE USE OF ARGON BEAM COAGULATION DURING ROBOTIC PARTIAL NEPHRECTOMY IN AN ANIMAL MODEL Andrew Harbin, Kumar Nadhan, James Mooney, and Daniel Eun Andrew HarbinAndrew Harbin More articles by this author , Kumar NadhanKumar Nadhan More articles by this author , James MooneyJames Mooney More articles by this author , and Daniel EunDaniel Eun More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1481AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Partial nephrectomy (PN) has become the standard of care for management of a small renal mass. While robotic partial nephrectomy (RPN) has been widely adopted as a minimally invasive option, one concern is the long-term effects of prolonged warm ischemia time (WIT) on renal function and cardiac health. Multiple technological and procedural advancements have been proposed to limit WIT, but most are technically difficult to perform. Argon beam coagulation (ABC) can be used to coagulate the base of a tumor fossa prior to performing formal renorrhaphy. This may eliminate the need for deep hemostatic suturing, thus allowing for earlier placement of renorrhaphy sutures and earlier hilar unclamping. We report our initial experience with ABC during RPN in a pig model. METHODS Six Yorkshire pigs underwent bilateral RPN using the Da Vinci Si Surgical system (Intuitive, Sunnyvale, CA). Because pig kidneys naturally bleed less than human kidneys, all pigs underwent systemic heparinization to simulate a human PN. After tumor excision, each pig underwent coagulation with the System 7550TM ABC (Conmed, Utica, NY) on one kidney and traditional renorrhaphy on the contralateral kidney. Kidney resection start/end time, hilum ready time, as well as total WIT and estimated blood loss (EBL) were recorded for each procedure. RESULTS All RPN were completed successfully. Mean WIT with traditional renorrhaphy was 7 minutes and 30 seconds, compared to only 4 minutes and 40 seconds in the ABC group (p=0.022), a difference of 2 minutes 50 seconds (38% reduction). There was no observed difference in EBL between the ABC and traditional renorrhaphy approach. CONCLUSIONS ABC may allow for a standardized reduction in risk of injury to PN patients by minimizing technical difficulty and, in turn, WIT. Because the ABC method does not require surgeons to learn additional maneuvers, this approach may have broader applicability than some of the previous attempts at reducing WIT. Further study is required to determine the relative effect on renal function. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e494-e495 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Harbin More articles by this author Kumar Nadhan More articles by this author James Mooney More articles by this author Daniel Eun More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP84-09 MULTICENTER VALIDATION OF ABILITY OF SURGEON ASSESSMENT OF RENAL PRESERVATION IN COMPARISON TO MEASUREMENT WITH 3D IMAGE ANALYSIS

You have accessJournal of UrologyKidney Cancer: Surgical Therapy VII1 Apr 2015MP84-09 MULTICENTER VALIDATION OF ABILITY OF SURGEON ASSESSMENT OF RENAL PRESERVATION IN COMPARISON TO MEASUREMENT WITH 3D IMAGE ANALYSIS Conrad Tobert, Toshio Takagi, Michael Liss, Hak Lee, Ithaar Derweesh, Steven Campbell, and Brian Lane Conrad TobertConrad Tobert More articles by this author , Toshio TakagiToshio Takagi More articles by this author , Michael LissMichael Liss More articles by this author , Hak LeeHak Lee More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , Steven CampbellSteven Campbell More articles by this author , and Brian LaneBrian Lane More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1976AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Baseline renal function and preservation of functioning renal parenchyma are the strongest predictors of function after partial nephrectomy (PN) for presumed renal cancer. Prior studies have confirmed that measurement of volume preservation with 3D imaging (3DVP) is accurate, but limited data exist to compare this time-consuming approach with surgeon assessment of volume preservation (SAVP). We validated the findings of a prior, single-surgeon series with a multi-institutional comparison of 3DVP and SAVP as predictors of renal function after PN. METHODS 3DVP and SAVP were calculated for 157 patients with cross-sectional imaging available from before and after PN. Renal functional outcomes were assessed with univariable and multivariable linear regression methods. RESULTS Median parenchymal preservation was 92% by 3DVP (72%-102%) and 92% by SAVP (70%-97%). 3DVP and SAVP were strongly correlated (p<0.0001) and no significant differences observed in the precision of SAVP assessments made by 13 individual surgeons (p>0.05). Both 3DVP and SAVP were strongly correlated with post-operative GFR (p<0.0001). Univariable analyses revealed that age, preoperative GFR, RENAL score, and each assessment were significant predictors of renal function (p<0.05), and parenchymal preservation was the strongest predictor in multivariable analyses (p<0.0001). Models using 3DVP and SAVP were statistically similar in ability to predict nadir GFR and latest GFR. CONCLUSIONS SAVP has now been validated in a multi-center cohort of PN patients, demonstrating it to provide a reliable estimate of renal functional preservation that is reproducible in contemporary practice. We propose that SAVP reporting should be performed routinely to facilitate analysis of PN outcomes. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1061 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Conrad Tobert More articles by this author Toshio Takagi More articles by this author Michael Liss More articles by this author Hak Lee More articles by this author Ithaar Derweesh More articles by this author Steven Campbell More articles by this author Brian Lane More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The association between renal tumour scoring system components and complications of partial nephrectomy.

We evaluate the associations between 3 renal tumour scoring systems and their components with perioperative complications of partial nephrectomy. A consecutive cohort of partial nephrectomy patients was analyzed. Patient characteristics were abstracted from medical records. PADUA scores (preoperative aspects and dimensions used for anatomic classification), RENAL (radius exophyic/endophytic nearness anterior/posterior location scoring) nephrometry scores, and Centrality index (C-index) were determined from preoperative axial images by 2 independent reviewers. Cases were evaluated for postoperative complications up to 30 days after surgery. Pre-specified complication definitions were used for 33 potential medical and surgical complications. Unadjusted and adjusted associations between overall scores, individual components, and complications were determined using log binomial regression. In total, 118 patients were included in the study. Of these, 36 (30.5%) surgical complications occurred in 27 (22.9%) patients. Fourteen (11.9%) were Clavien grade ≥3. Overall PADUA score was significantly associated with surgical and overall complications after adjusting for potential confounders. Among all components of the 3 scoring systems, only tumour diameter and exophytic/endophytic nature of the tumour were significantly associated with complications after adjusting for the other components of the respective scoring system (p < 0.05). Renal tumour scoring systems may help predict the risk of complications after partial nephrectomy. Further refinement of current systems is required. A first step would be to include only components that are significantly associated with complications.

Comparative Outcome of Computed Tomography-guided Percutaneous Radiofrequency Ablation, Partial Nephrectomy or Radical Nephrectomy in the Treatment of Stage T1 Renal Cell Carcinoma.

Renal cell carcinoma (RCC) accounts for 3% of all cancers in adults. The indications for Radiofrequency Ablation (RFA) for renal carcinomas include T1a (tumor 4 cm or less, limited to the kidney), elderly patients, renal impairment, comorbidities, poor surgical candidate, and multiple bilateral renal masses. We retrospectively reviewed medical records, specifically investigating the indications, complications and outcomes of RFA and nephrectomy for treatment of RCC in a tertiary medical center with a predominantly Hispanic patient population. Forty-nine patients with RCC were evaluated. Nine patients had RFA, 9 had partial nephrectomy and 31 had radical nephrectomy. All patients among the 3 groups had stage T1N0M0 RCC at diagnosis. Tumor recurrence was observed in 2 (22%) patients that had RFA, one (11%) patient that had partial nephrectomy and no patients that had radical nephrectomy. One patient had recurrence of the tumor at the opposite kidney pole from the initial RFA site 4 years later. This particular patient did not have any tumor recurrence at the site of the initial RFA. A second RFA was performed on the recurrent tumor with no recurrence upon subsequent follow up visits. The second patient had recurrence of the RCC on 1 year follow that was discovered to be sarcomatoid RCC, which is an aggressive type with a poor prognosis. Our results support the clinical utility of RFA in patients with stage T1 RCC who are poor surgical candidates or those with reduced renal function. The clinical utility of RFA as an equally effective approach when compared to partial nephrectomy in patients with stage T1 RCC that meet strict indications for the procedure. The treatment choice should be individualized and based on the characteristics of the renal tumor such as size, location and histological type of RCC. We conclude that RFA presents a safe treatment choice for patients with RCC if long term follow up is maintained.

Presurgical sunitinib reduces tumor size and may facilitate partial nephrectomy in patients with renal cell carcinoma

ObjectiveTo determine whether presurgical sunitinib reduces primary renal cell carcinoma (RCC) size and facilitates partial nephrectomy (PN). MethodsData from potential candidates for PN treated with sunitinib with primary RCC in situ were reviewed retrospectively. Primary outcome was reduction in tumor bidirectional area. ResultsIncluded were 72 potential candidates for PN who received sunitinib before definitive renal surgery on 78 kidneys. Median primary tumor size was 7.2cm (interquartile range [IQR]: 5.3–8.7cm) before and 5.3cm (IQR: 4.1–7.5cm) after sunitinib treatment (P<0.0001), resulting in 32% reduction in tumor bidirectional area (IQR: 14%–46%). Downsizing occurred in 65 tumors (83%), with 15 partial responses (19%). Tumor complexity per R.E.N.A.L. score was reduced in 59%, with median posttreatment score of 9 (IQR: 8–10). Predictors of lesser tumor downsizing included clinical evidence of lymph node metastases (P<0.0001), non–clear cell histology (P = 0.0017), and higher nuclear grade (P = 0.023). Surgery was performed for 68 tumors (87%) and was not delayed in any patient owing to sunitinib toxicity. Grade≥3 surgical complications occurred in 5 patients (7%). PN was performed for 49 kidneys (63%) after sunitinib, including 76% of patients without and 41% with metastatic disease (P = 0.0026). PN was completed in 100%, 86%, 65%, and 60% of localized cT1a, cT1b, cT2, and cT3 tumors, respectively. ConclusionPresurgical sunitinib leads to modest tumor reduction in most primary RCC, and many patients can be subsequently treated with PN with acceptable morbidity and preserved renal function. A randomized trial is required to definitively determine whether presurgical therapy enhances feasibility of PN.

Renal tumour anatomical characteristics and functional outcome after partial nephrectomy

Objective. Anatomical features of renal tumours may be useful in predicting glomerular filtration rate (GFR) after partial nephrectomy. In this study, anatomical classification systems (ACSs) were compared to predict changes in renal function after surgery. Materials and methods. A group of 294 patients with T1 renal tumours receiving partial nephrectomy between January 2006 and June 2013 were identified from the institutional kidney tumour database. Preoperative images from computed tomography or magnetic resonance imaging were reviewed to assess diameter, PADUA (preoperative aspects and dimensions used for an anatomical) classification score, RENAL (radius, exophytic/endophytic properties of the tumour, nearness of tumour deepest portion to the collecting system or sinus, anterior/posterior descriptor and location relative to polar lines) nephrometry score, centrality index (C index) and renal tumour invasion index (RTII). GFR was estimated using the Modification of Diet in Renal Disease equation preoperatively and 3 months after operation. Linear and logistic regression were applied as statistical methods. Results. Mean tumour diameter was 3.0 ± 2.2 cm (range 1.0–7.0 cm). GFR was 85 ± 22 ml/min/1.73 m² before the operation and 77 ± 21 ml/min/1.73 m² (–8% change) 3 months after the operation. In univariate linear regression, the percentage change in GFR was weakly but statistically significantly associated with surgical approach (p = 0.04), indication for nephron sparing (p = 0.02), preoperative GFR (p < 0.001), PADUA (p = 0.02), RENAL (p = 0.01) and RTII (p = 0.003). In multivariate logistic regression analysis among patients with tumours 3 cm or larger, PADUA (odds ratio 1.55, p = 0.021) and RTII (odds ratio 3.87, p = 0.037) predicted at least a 20% reduction in GFR. Conclusions. Renal tumour ACSs may be clinically useful in predicting changes in renal function after partial nephrectomy in patients with larger tumours. The performance of RTII is equal to that of other ACSs in predicting changes in GFR.

Bone health and chronic kidney disease: another reason for partial nephrectomy?

To review the potential role of surgically induced nephron loss in calcium metabolism and its consequences on bone heath, and possible impact of surgical management of renal tumors on bone disorders. With long-term oncological equivalence to radical nephrectomy and renal functional benefit, partial nephrectomy is the reference standard for management of clinical T1 renal tumors. Impact of nephron preservation on reduction of cardiovascular sequelae of chronic kidney disease is controversial. Reports from preclinical models provide a mechanism for surgically induced nephron loss leading to vitamin D and calcium metabolism dysregulation, resulting in osteoporosis. Emerging retrospective data also suggest that nephron preservation in setting of surgical treatment of renal malignancy may reduce risk of chronic kidney disease and sequelae, including osteoporosis and fractures. The magnitude and broader impact is unclear as other reports suggest that surgically induced chronic kidney disease is more stable than its medical counterpart. Preclinical models and retrospective series suggest that surgically induced nephron loss is independently associated with development of osteopenia and fractures and biochemical events, which may lead to these subsequent events. Although prospective data is requisite, it is reasonable to prioritize nephron preservation when feasible in patients with preexisting disorders of bone metabolism, or to consider partial nephrectomy in patients with risk factors for osteoporosis.

Nephron-sparing surgery for tumors in a solitary kidney.

Presence of a tumor in a solitary kidney is an absolute indication for performing nephron-sparing surgery (NSS). In the past two decades, new modalities for treatment of small renal mass have emerged but despite their evolution and promising results, partial nephrectomy remains the cornerstone of surgical treatment in this setting. Herein, we review the literature surrounding NSS in patients with a solitary kidney. Data from large retrospective, single and multi-institutional series indicate that open partial nephrectomy in patients with a solitary kidney can achieve oncological control as well as renal function preservation with acceptable complication profile. Available data indicate that employing parenchymal cooling can mitigate the deleterious effects of prolonged clamp time during partial nephrectomy. Introduction of laparoscopic and, more recently, robotic approach have allowed minimally invasive approach in selected patients undergoing partial nephrectomy. Large comparative studies comparing minimally invasive approaches to open technique are lacking. Established and emerging NSS techniques along with our better understating of the factors affecting function after surgery have fostered improvement of delivery of care in the setting of renal tumor(s) in a solitary kidney. Future developments should focus on minimizing the invasiveness of treatments while further improving cancer control and functional preservation.

PYJ19: Robot-assisted laparoscopic partial nephrectomy in patients with previous abdominal surgery

PYJ19: Robot-assisted laparoscopic partial nephrectomy in patients with previous abdominal surgery

PE72: Body Mass Index (BMI) has no effect on perioperative parameters in robot assisted partial nephrectomy patients

PE72: Body Mass Index (BMI) has no effect on perioperative parameters in robot assisted partial nephrectomy patients

Identifying Incidence and Risk Factors for Venous Thromboembolism among Partial and Radical Nephrectomy Patients for Kidney Cancer

Identifying Incidence and Risk Factors for Venous Thromboembolism among Partial and Radical Nephrectomy Patients for Kidney Cancer

Robotic retroperitoneal partial nephrectomy: a step‐by‐step guide

To describe a step-by-step guide for successful implementation of the retroperitoneal approach to robotic partial nephrectomy (RPN) PATIENTS AND METHODS: The patient is placed in the flank position and the table fully flexed to increase the space between the 12th rib and iliac crest. Access to the retroperitoneal space is obtained using a balloon-dilating device. Ports include a 12-mm camera port, two 8-mm robotic ports and a 12-mm assistant port placed in the anterior axillary line cephalad to the anterior superior iliac spine, and 7-8 cm caudal to the ipsilateral robotic port. Positioning and port placement strategies for successful technique include: (i) Docking robot directly over the patient's head parallel to the spine; (ii) incision for camera port ≈1.9 cm (1 fingerbreadth) above the iliac crest, lateral to the triangle of Petit; (iii) Seldinger technique insertion of kidney-shaped balloon dilator into retroperitoneal space; (iv) Maximising distance between all ports; (v) Ensuring camera arm is placed in the outer part of the 'sweet spot'. The retroperitoneal approach to RPN permits direct access to the renal hilum, no need for bowel mobilisation and excellent visualisation of posteriorly located tumours.

Nephrometry scores: Interobserver reproducibility and perioperative factors prediction

ObjectivesTo validate the relation of the nephrometry scores in a series of patients who underwent partial nephrectomy with perioperative parameters and the urologist–radiologist reproducibility. Materials and methodsA retrospective study of open and laparoscopic partial nephrectomy patients performed between 2005 and 2012 registered in prospective filled out database. An urologist and a radiologist calculated the RENAL, PADUA and C-index for 86 patients. We carried out a comparative study of the results using the Spearman and Pearson correlation indexes. ResultsDistribution according to the complexity of the tumors with the RENAL calculation was: 42 (49%) low, 35 (41%) moderated and 9 (11%) high complexity. According to PADUA: 35 (41%) low complexity, 32 (37%) intermediate and 19 (22%) high. No statistically significant correlation was found for the appearance of operative complications and the pathology results in case of RENAL and PADUA. A correlation was found in the case of PADUA in relation to the warm ischemia time. Positive correlation according to Spearman's index was found in RENAL, PADUA and C-index between urologist and radiologist evaluations. ConclusionsNephrometry scores can be a useful tool to plan the surgical technique or approach. However, it is not clear if they are really predictors of surgical or pathologic parameters. The correlation between the urologist and radiologist seems to be sufficient to recommend their use by both specialties.

Reply

We appreciate this thoughtful commentary and agree that estimated glomerular filtration rate (eGFR) does not represent a perfect metric to evaluate any clinical benefits attributable to integration of fluorescence-enhanced selective clamping into robotic partial nephrectomy. However, certain points should be considered before using this as a basis to conclude that the results presented here are without meaning. First, although our patient population does indeed display a wide range of postoperative eGFR and includes some with paradoxical eGFR increases (in both control and selective clamp cohorts), such a distribution is consistent with literature values from a number of prior large and multi-institutional studies. 1 Scoll B.J. Uzzo R.G. Chen D.Y. et al. Robot-assisted partial nephrectomy: a large single-institutional experience. Urology. 2010; 75: 1328-1334 Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar , 2 Patel M.N. Krane L.S. Bhandari A. et al. Robotic partial nephrectomy for renal tumors larger than 4 cm. Eur Urol. 2010; 57: 310-316 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar , 3 Kumar R.K. Sammon J.D. Kaczmarek B.F. et al. Robot-assisted partial nephrectomy in patients with baseline chronic kidney disease: a multi-institutional propensity score-matched analysis. Eur Urol. 2014; 65: 1205-1210 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Second, although eGFR is certainly sensitive to the multitude of factors identified by the commentators, these would need to have preferentially affected eGFR in 1 of the 2 groups for a detection bias to be introduced. In the absence of any such evidence, one would assume that eGFR variability affected both the control and selective clamp cohorts in a similar manner. Lastly, we agree that future analyses of this technique in the present and other populations would benefit by integrating degree of parenchyma sparing, as well as additional patient or tumor characteristics, outcome metrics, and longer follow-up. Such work could further delineate the contribution of minimized ischemia vs parenchymal volume sparing in ultimate renal function, while perhaps providing additional guidance on indications for this and other approaches to partial nephrectomy. In the interim, however, we believe that the results presented here serve as promising evidence of successful intraoperative minimization of ischemic kidney injury. Editorial CommentUrologyVol. 84Issue 2PreviewThe authors have published excellent results with the use of near-infrared imaging (NIRF) and selective clamp robotic partial nephrectomy. We use NIRF, as the authors do, to facilitate selective clamping and believe the technology to be highly predictable for renal perfusion. However, one may speculate that there may be an unrecognized error in the quantified renal functional benefits. Full-Text PDF

Correlations of Tumor Size, RENAL, Centrality Index, Preoperative Aspects and Dimensions Used for Anatomical, and Diameter-axial–polar Scoring With Warm Ischemia Time in a Single Surgeon's Series of Robotic Partial Nephrectomy

To evaluate the association of tumor size, renal nephrometry systems (RNSs), including RENAL, centrality index (C-index), preoperative aspects and dimensions used for anatomical, and diameter-axial-polar scoring, and individual categories of these RNSs with warm ischemia time (WIT). A single surgeon's series of robotic partial nephrectomy patients for whom RNS was available were identified from 2012 to 2013. Spearman's correlation was used to evaluate associations between the RNSs and individual categories and WIT. Analysis was performed based on 69 patients with a median tumor size of 3.5 cm (interquartile range 2.6-4.2). Overall, each scoring system and tumor size were found to have a statistically significant association with the WIT, with the C-index system exhibiting the strongest correlation (coefficient: -0.609, P <.001), which was confirmed in the series beyond the surgeon's learning curve. In the subgroup of relatively small renal masses (<3 cm), there was a statistically significant association between the C-index, preoperative aspects and dimensions used for anatomical, and diameter-axial-polar systems with WIT. However, for tumors >3 cm, none of the RNSs was found to have a statistically significant correlation with WIT, except for the tumor size (coefficient: 0.354, P = .027). For subcategories, axial scoring was found to have a consistent statistically significant correlation with WIT. Overall, each RNS and tumor size strongly correlated with WIT in patients undergoing robotic partial nephrectomy. However, the RNS outperformed tumor size in small (<3 cm) renal masses with an optimal discriminating power, whereas for relatively larger (>3 cm) tumors, WIT was significantly dependent on tumor size, and every centimeter may count.

Enhanced computed tomography after partial nephrectomy in early postoperative period to detect asymptomatic renal artery pseudoaneurysm

We systematically examined the incidence and potential implications of renal artery pseudoaneurysm occurring after partial nephrectomy detected by computed tomography screening in the early postoperative period. Between January and December 2012, 117 patients underwent enhanced screening computed tomography on the fourth postoperative day after partial nephrectomy to evaluate for renal artery pseudoaneurysm. The size of the renal artery pseudoaneurysm and follow-up imaging were utilized to decide on pre-emptive angioembolization. Patient characteristics, tumor specifics and surgical data were analyzed. A total of 17 of 117 patients (15%) were found to have renal artery pseudoaneurysm on early postoperative computed tomography. Renal artery pseudoaneurysm occurred in nine of 73 open partial nephrectomy patients (12.3%) and eight of 44 laparoscopic partial nephrectomy patients (18.2%). One early patient experienced a postoperative bleed on postoperative day 9 after diagnosis of a 3.5-mm diameter renal artery pseudoaneurysm on postoperative day 3, and this patient was successfully managed with angioembolization. There were no other postoperative bleeding episodes. Rapid growth of a renal artery pseudoaneurysm was observed in a second patient who was treated with pre-emptive angioembolization. Five patients were diagnosed with small renal artery pseudoaneurysm (2-4 mm) on postoperative day 4 and observed with follow-up imaging showing resolution of the renal artery pseudoaneurysm. Another 10 patients were diagnosed with larger renal artery pseudoaneurysm (≥4 mm) and were managed with pre-emptive angioembolization. Early postoperative computed tomography screening is able to detect modest rates of asymptomatic renal artery pseudoaneurysm. The rate of postoperative bleed remained low with a policy of selective angioembolization. Renal artery pseudoaneurysm size and interval enlargement might indicate the risk of rupture. Further studies are required to assess the potential role of pre-emptive angioembolization.

Nefrometrías: reproducibilidad interobservador y predicción de factores perioperatorios

ObjectivesTo validate the relation of the nephrometry scores in a series of patients who underwent partial nephrectomy with perioperative parameters and the urologist-radiologist reproducibility. Material and methodsA retrospective study of open and laparoscopic partial nephrectomy patients performed between 2005 and 2012 registered in prospective filled out database. An urologist and a radiologist calculated the R.E.N.A.L., PADUA and C-index for 86 patients. We carried out a comparative study of the results using the Spearman and Pearson correlation indexes. ResultsDistribution according to the complexity of the tumors with the RENAL calculation was: 42 (49%) low, 35 (41%) moderated and 9 (11%) high complexity. According to PADUA: 35 (41%) low complexity, 32 (37%) intermediate and 19 (22%) high. No statistically significant correlation was found for the appearance of operative complications and the pathology results in case of RENAL and PADUA. A correlation was found in the case of PADUA in relation to the warm ischemia time. Positive correlation according to Spearman's index was found in RENAL, PADUA and C-index between urologist and radiologist evaluations. ConclusionsNephrometry scores can be a useful tool to plan the surgical technique or approach. However, it is not clear if they are really predictors of surgical or pathologic parameters. The correlation between the urologist and radiologist seems to be sufficient to recommend their use by both specialties.

MP54-04 PARTIAL NEPHRECTOMY IS EQUIVALENT TO ACTIVE SURVEILLANCE IN PRESERVING RENAL FUNCTION FOR PATIENTS WITH SMALL RENAL MASSES

INTRODUCTION AND OBJECTIVES: Active surveillance (AS) for patients with a small renal mass (SRM) is considered an acceptable alternative to surgery due to the slow growth of such tumors, low risk of metastasis, and presumed retention of renal function. We previously demonstrated a moderate decline in renal function for patients on AS in the Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) Registry. We now sought to compare this with the decline following extirpative modalities. We also correlated tumor growth rate with renal functional decline in AS patients. METHODS: The multi-institutional DISSRM Registry opened January 1, 2009. Patients with SRMs 4cm were entered into AS or intervention arms. Those electing AS followed an imaging protocol. Growth rates of masses were calculated based on changes in diameter. GFR was calculated with the Modification of Diet in Renal Disease formula. GFR change was calculated from the first value for surveillance patients or the pre-operative value for intervention patients, to the most recent value. Linear regression was used to determine the effects of study arm and growth rate on GFR, while controlling for the impact of demographics, comorbidities, and tumor histology. RESULTS: The difference in average GFR decline between the 66 partial nephrectomy (PN) patients and the 67 AS patients was not significant (1.9 vs 0.5, p1⁄40.270). In contrast, there was a significantly greater decline in the 15 radical nephrectomy (RN) patients compared to the AS patients (9.2 vs 0.5, p1⁄40.001). Average follow up time for AS, PN, and RN patients was 20, 19, and 16 months, respectively. On regression analysis while controlling for comorbidities, GFR was again found to decline faster in RN (p1⁄40.016) but not PN (p1⁄40.778) patients compared to AS patients. Average growth rate of masses in the AS arm was 0.19 cm/year. There was no significant difference in GFR change between AS patients whose tumors increased in size over their enrollment and those whose tumors decreased in size, as shown in the table (p1⁄40.260). On regression analysis the tumor growth rate did not significantly affect the rate of GFR decline while controlling for comorbidities (p1⁄40.915). CONCLUSIONS: AS for the small renal mass yields equivalent preservation of GFR when compared to PN, while both modalities are superior to RN. Preservation of renal function during AS is unaffected by growth rate. These renal function outcomes should be considered when making treatment decisions. N GFR Declined No change in GFR GFR Rose

MP64-06 RECURRENCE AND SURVIVAL AFTER PARTIAL VERSUS RADICAL NEPHRECTOMY FOR T1 RENAL MASS

You have accessJournal of UrologyKidney Cancer: Localized V1 Apr 2014MP64-06 RECURRENCE AND SURVIVAL AFTER PARTIAL VERSUS RADICAL NEPHRECTOMY FOR T1 RENAL MASS Connor M. Forbes, Ricardo A. Rendon, Antonio Finelli, Anil Kapoor, Ronald B. Moore, Rodney H. Breau, Louis Lacombe, Jun Kawakami, Darrel E. Drachenberg, Stephen E. Pautler, Michael Jewett, Zhihui Liu, Simon Tanguay, and Peter C. Black Connor M. ForbesConnor M. Forbes More articles by this author , Ricardo A. RendonRicardo A. Rendon More articles by this author , Antonio FinelliAntonio Finelli More articles by this author , Anil KapoorAnil Kapoor More articles by this author , Ronald B. MooreRonald B. Moore More articles by this author , Rodney H. BreauRodney H. Breau More articles by this author , Louis LacombeLouis Lacombe More articles by this author , Jun KawakamiJun Kawakami More articles by this author , Darrel E. DrachenbergDarrel E. Drachenberg More articles by this author , Stephen E. PautlerStephen E. Pautler More articles by this author , Michael JewettMichael Jewett More articles by this author , Zhihui LiuZhihui Liu More articles by this author , Simon TanguaySimon Tanguay More articles by this author , and Peter C. BlackPeter C. Black More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1923AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Partial nephrectomy for early stage renal cancer preserves renal function better than radical nephrectomy and is generally considered oncologically sound. The Intergroup EORTC prospective randomized phase 3 trial comparing oncologic outcomes after partial versus radical nephrectomy, however, has cast some doubt on this premise. This study aims to elucidate outcomes in partial versus radical nephrectomy for early stage tumours in the Canadian population. METHODS From 1989-2013, 1065 patients with a first occurrence of a clinical T1 renal mass who underwent partial or radical nephrectomy were identified from the Canadian Kidney Cancer Information System (CKCis), a national database of 2927 renal cancer patients. Baseline clinical, surgical, and pathologic parameters were collected. Progression-free survival was compared between types of surgery using a Cox proportional hazards model, adjusted for age at diagnosis, gender, clinical T stage, and diagnosis year. RESULTS Inclusion criteria were met by 726 partial and 339 radical nephrectomy patients, with median follow-up of 2.7 and 3.8 years, respectively. Pre-operative characteristics, surgical parameters and pathologic findings were similar in both groups, although patients undergoing radical nephrectomy more commonly had T1b disease (46% vs 19%) (Table 1). Unadjusted Kaplan-Meier progression-free survival was lower in radical than partial nephrectomy (log rank test, p=0.04). However, in the multivariable analysis, time to progression did not differ between radical and partial nephrectomy (hazard ratio 1.63, p=0.12, 95% C.I. 0.88 – 3.0). CONCLUSIONS These results indicate that progression-free survival does not differ between radical and partial nephrectomy in patients with T1 renal masses. This suggests that the selection of surgical approach should be based on other factors, including technical feasibility, potential complications and preservation of renal function. Table 1. Patient, tumour, and surgery characteristics Parameter Sub-Parameter Partial Nephrectomy Radical Nephrectomy Number - 726 (68%) 339 (32%) Age - 59 60 Gender Male 458 (63%) 208 (61%) - Female 268 (37%) 131 (39%) Clinical T stage T1 57 (8%) 25 (7%) - T1a 521 (72%) 130 (38%) - T1b 123 (19%) 118 (46%) Pathological N-stage N0 119 (17%) 93 (27%) - N1 2 (0%) 6 (2%) - Nx 601 (83%) 239 (71%) Histology chromophobe 62 (9%) 30 (9%) - clear cell 472 (68%) 240 (74%) - papillary 133 (19%) 51 (16%) - renal cell carcinoma 1 (0%) 1 (0%) - other 26 (4%) 4 (1%) Grade 1 98 (15%) 31 (10%) - 2 358 (56%) 168 (55%) - 3 169 (26%) 84 (28%) - 4 17 (3%) 21 (7%) Margin Status negative 649 (93%) 318 (98%) - positive 48 (7%) 5 (2%) Surgery open 402 (56%) 76 (23%) - laparoscopic 277 (38%) 255 (77%) - robotic 40 (6%) 1 (0%) Duration of surgery (min) - 153 163 Blood loss (mL) - 303 193 © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e702-e703 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Connor M. Forbes More articles by this author Ricardo A. Rendon More articles by this author Antonio Finelli More articles by this author Anil Kapoor More articles by this author Ronald B. Moore More articles by this author Rodney H. Breau More articles by this author Louis Lacombe More articles by this author Jun Kawakami More articles by this author Darrel E. Drachenberg More articles by this author Stephen E. Pautler More articles by this author Michael Jewett More articles by this author Zhihui Liu More articles by this author Simon Tanguay More articles by this author Peter C. Black More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD16-06 PATIENT-BASED 3D PRINTED ORGAN MODEL PROVIDES TANGIBLE SURGICAL NAVIGATION: A NOVEL AID TO CLAMPLESS PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: To incorporate a computer-assisted volumetric assessement of potential spared paranchyma from preoperative CT scans to predict chronic kidney disease (CKD) at 6 months from extirpative renal surgery. METHODS: We performed a retrospecitve analysis of radical (RN) or partial nephrectomy (PN) patients with compatable CT scans from our institution. We used Vitrea v.6.3 computer software program (Vital Images, Minnetonka, MN) to create a 3D volume of the tumor, 1 cm margin, ipsilateral kidney (Figure), and contralateral kidney (cm3). Primary outcome analyzed was development of postoperative CKD (estimated glomerular filtration rate<60 mL/min/ 1.73 m2 by MDRD equation). We performed linear regression using preoperative GFR, total RENAL nephrometry score, and volumes (excluding tumor) to predict 6-month GFR and tested with 5-fold cross validation. The GFR generated by our analysis was compared to postoperative eGFR for prediction of CKD to calculate test characteristics [sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV)] and area under the curve (AUC). RESULTS: We included 130 patients (79 PN/51 RN) from our database from 3/2000 to 2/2013 and a median eGFR follow-up of 6.1 (4.2-36) months. Median age was 58 (IQR: 49-67), 83 (61%) men, and 53 (57%) Caucasian. Median tumor volume was 24.6 (IQR: 7e82) cm3. The most signifant corrlates of post operative renal function were preoperative eGFR (p<0.001), Isipateral volume (p<0.001), and estimated margin volume (p<0.001). RENAL nephromery score (p1⁄40.285) and contralateral renal volume (p1⁄40.418) were non-signficant. In multivariate linear regression, the predicted GFR correlated with postoperative GFR at 6 months (R21⁄40.518, p<0.001). Using the model, prediction of postoperative CKD noted an AUC of 0.752 (95% CI 0.662-0.842; p1⁄4<0.001) with accompanying sensitivity (86.7%), specificity (63.6%), positive predicitve value (76.5%), and negative predictive value (77.8%). CONCLUSIONS: Preoperative GFR and computer assisted predicted renal volume spared are able to predict 6-month postoperative occurance of CKD. While prospective validation is requisite, this technique may provide valuable information regarding risk of postoperative CKD in clincial decision-making regarding partial or radical nephrectomy and post-operative expectations.