Patients Undergoing Radical Nephrectomy Research Articles

Normothermic cardiopulmonary bypass and beating heart surgery for renal cell cancer with tumor thrombus extension into inferior vena cava and right atrium: a less invasive strategy.

Management of renal cell carcinoma (RCC) with inferior vena cava (IVC) extension is one of the greatest challenges in urology. The gold standard treatment includes extracorporeal circulation and deep hypothermic circulatory arrest (DHCA). However, this surgical treatment has an impact on survival and prognosis. We aim to present a less invasive surgical approach for the treatment of level III and IV IVC thrombi in RCC. We identified all patients undergoing radical nephrectomy and thrombectomy at our Institution between 2016 and 2020. Patients with level IV thrombi were treated with a combined thoracic and abdominal procedure: beating heart surgery with normothermic cardiopulmonary bypass (CPB) was used for thrombus retrieval. Level III thrombi were approached exclusively through an abdominal access. We identified 12 patients treated with radical nephrectomy and thrombectomy among 243 patients undergoing radical nephrectomy for RCC. Mean age was 69.3 years, most patients were in T3c clinical stage, without lymph-node involvement (75%) and no metastases (66.7%); 58.3% of patients had Mayo III thrombus classification. Median intensive care unit stay was 2 days and total in-hospital stay 10.5 days. In-hospital mortality was 0%, with a 66.6% survival rate at 2 years. Beating heart surgery with normothermic CPB can be considered a less invasive method for radical resection of Mayo level IV IVC thrombi. This surgical approach is safe and feasible, with good in-hospital and short-term outcomes.

Age Does Not Impact Cancer Specific Mortality: From Sub-Distributional and Cause-Specific Hazard Analysis in RCC Patients Undergoing Radical Nephrectomy and Thrombectomy

ObjectiveTo assess the impact of age on cancer-specific mortality (CSM) and other-cause mortality (OCM) in patients undergoing radical nephrectomy with thrombectomy (RNTx) for renal cell carcinoma (RCC) with venous thrombus. Patients and MethodsWe retrospectively analyzed 196 patients who underwent RNTx for RCC with venous thrombus between 1990 and 2018 at a single tertiary referral center. Patients were categorized into three age groups: <60, 60-69, and ≥70 years. The cumulative incidence function (CIF) for CSM and OCM was calculated using the Aalen-Johansen estimator, and hazard ratios (HR) from sub-distributional hazard (SDH) and cause-specific hazard (CSH) models were employed to assess the impact of age on mortality. ResultsThe median follow-up was 40.5 months. Of the 196 patients, 105 experienced disease progression, 125 had cancerrelated deaths, and 155 died from any cause. Perioperative outcomes, including ICU admission, 90-day readmission, and 90-day mortality, were similar across age groups. The CIF for 5-year CSM differed significantly among age groups (p = 0.032), though this difference was not observed at 10 years. OCM increased significantly with age, particularly in the ≥70 group at 10 years (p = 0.045). Multivariable SDH and CSH models showed no significant differences in CSM between age groups. ConclusionWhile age was associated with increased OCM, it did not significantly impact the hazard of CSM. Older age alone should not be considered a contraindication for surgical intervention in RCC with venous thrombus.

Is fat quantification based on proton density fat fraction useful for differentiating renal tumor types?

This study retrospectively assessed the diagnostic accuracy of fat quantification based on proton density fat fraction (PDFF) for differentiating renal tumors. In this retrospective study, 98 histologically confirmed clear cell renal cell carcinomas (ccRCCs), 35 papillary renal cell carcinomas (pRCCs), 14 renal oncocytomas, 16 chromophobe renal cell carcinomas (chRCCs), 10 lymphomas, 19 uroepithelial tumors, 10 lipid-poor angiomyolipomas (AMLs), and 25 lipid-rich AMLs were identified in 226 patients (127 males and 99 females) over 5years. All patients underwent multiparametric kidney MRI. The MRI protocol included an axial plane and a volumetric 3D fat fraction sequence known as mDIXON-Quant for PDFF measurement. Demographic data were recorded, and PDFF values were independently reviewed by two radiologists blinded to pathologic results. MRI examinations were performed using a 1.5T system. MRI-PDFF measurements were obtained from the solid parts of all renal tumors. Fat quantification was performed using a standard region of interest for each tumor, compared to histopathological diagnoses. Sensitivity and specificity analyses were performed to calculate the diagnostic accuracy for each histopathological tumor type. Nonparametric variables were compared among the subgroups using the Kruskal-Wallis H test and Mann Whitney U test. P-values < 0.05 were considered statistically significant. In all, 102 patients underwent partial nephrectomy, 70 patients underwent radical nephrectomy, and the remaining 54 had biopsies. Patient age (mean: 58.11years; range: 18-87years) and tumor size (mean: 29.5mm; range: 14-147mm) did not significantly differ across groups. All measurements exhibited good interobserver agreement. The mean ccRCC MRI-PDFF was 12.6 ± 5.06% (range: 11.58-13.61%), the mean pRCC MRI-PDFF was 2.72 ± 2.42% (range: 2.12-3.32%), and the mean chRCC MRI-PDFF was 1.8 ± 1.4% (range: 1.09-2.5%). Clear cell RCCs presented a significantly higher fat ratio than other RCC types, uroepithelial tumors, lymphomas, and lipid-poor AMLs (p < 0.05). Lipid-rich AMLs demonstrated a very high fat ratio. MRI-PDFF facilitated accurate differentiation of ccRCCs from other renal tumors with high sensitivity and specificity.

23 Pre-surgical visceral adipose tissue may be a novel pre-surgical risk factor for acute kidney injury among clear cell renal cell cancer patients undergoing radical nephrectomy

Abstract Background Patients with renal cancer undergoing partial (PN) or radical nephrectomy (RN) are at risk for acute kidney injury (AKI). Established risk factor for AKI include baseline comorbidities (e.g., obesity, hypertension), normal renal parenchymal loss, and ischemia-reperfusion injury. Pre-surgical body composition may be an overlooked modifiable patient characteristic that influences risk of AKI. We hypothesized that patients with higher visceral adipose tissue quantity or lower skeletal muscle quantity would have a higher risk of AKI. Methods The RESOLVE study at Memorial Sloan Kettering Cancer Center is a retrospective study of 1239 patients with stage I-III clear cell renal cell carcinoma (ccRCC) undergoing PN or RN from 2000 to 2020. We excluded from analysis patients with solitary kidney, those without preoperative serum creatinine (sCr) measurements, and those without a sCr measurement within seven days following nephrectomy, yielding a study population of 1,200 ccRCC patients with longitudinal sCr assessment (n=754 PN; n=446 PN). AKI was defined as a binary variable using the Kidney Disease – Improving Global Outcomes (KDIGO) criteria, based on a threshold of either a 1.5x relative or 0.3 mg/dl absolute increase in sCr within seven days. The cross-sectional areas and radiodensities of visceral adipose and skeletal muscle tissues were determined from pre-surgical computed tomography (CT) scans at the third lumbar vertebrae using Automatica software. We used generalized linear models with a binomial family and identity link to estimate seven-day risk differences (RD) and 95% confidence intervals in subgroups defined by surgery type. Results AKI was more frequent among patients undergoing RN (66% vs 26% among PN). Male patients, those with higher eGFR prior to surgery, those with lower stage/smaller tumors, and those with a history of hyperlipidemia more frequently experienced AKI in the post-operative period. No associations were observed with other reported comorbidities (diabetes, hypertension). While no association was observed between BMI and risk of AKI, visceral adipose and skeletal muscle variables were significantly associated with risk of AKI in univariate models. After adjustment for age, sex, comorbidities, and other body composition variables, only higher visceral adipose tissue quantity remained significantly associated with increased risk of AKI [RD per 40 unit increase (95% CI): 5.2 (1.3, 9.2)]. Muscle characteristics were not associated with AKI in multivariable models. Among patients undergoing PN, we observed a higher frequency of AKI among male patients, those with higher stage/larger tumors, and those with longer ischemia times. No significant associations were observed with comorbidity histories. In univariate models, visceral adipose tissue quantity and quality as well as skeletal muscle quantity were associated with AKI risk; however, after adjustment for age, sex, comorbidities, and other body composition variables, we observed no significant associations between any body composition feature and AKI in patients undergoing PN. Conclusions Associations between pre-surgical body composition and risk of AKI vary by surgery type. Visceral adipose tissue quantity was associated with risk of AKI among patients undergoing RN, but not PN. This finding may be relevant for patient counseling, consideration for nephron-sparing surgery, and development of interventions to lower visceral adipose tissue quantity. Future studies should evaluate the impact of both pre-surgical and post-surgical change in body composition in relation on chronic kidney disease after nephrectomy.

Long-term functional outcomes in patients undergoing radical nephrectomy for renal cell carcinoma and tumor thrombus.

Up to 15% of patients with locally advanced renal cell carcinoma (RCC) harbors tumor thrombus (TT). In those cases, radical nephrectomy (RN) and thrombectomy represents the standard of care. We assessed the impact of TT on long-term functional and oncological outcomes in a large contemporary cohort. Within a prospective maintained database, 1207 patients undergoing RN for non-metastatic RCC between 2000 and 2021 at a single tertiary centre were identified. Of these, 172 (14%) harbored TT. Multivariable logistic regression analyses evaluated the impact of TT on the risk of postoperative acute kidney injury (AKI). Multivariable Poisson regression analyses estimated the risk of long-term chronic kidney disease (CKD). Kaplan Meier plots estimated disease-free survival and cancer specific survival. Multivariable Cox regression models assessed the main predictors of clinical progression (CP) and cancer specific mortality (CSM). Patients with TT showed lower BMI (24 vs. 26kg/m2) and preoperative Hb (11 vs. 14g/mL; all-p < 0.05). Clinical tumor size was higher in patients with TT (9.6 vs. 6.5cm; p < 0.001). After adjusting for potential confounders, the presence of TT was significantly associated with a higher risk of postoperative AKI (OR 2.03, 95% CI 1.49-3.6; p < 0.001) and long-term CKD (OR: 1.32, 95% CI 1.10-1.58; p < 0.01). Notably, patients with TT showed worse long-term oncological outcomes and TT was a predictor for CP (2.02, CI 95% 1.49-2.73, p < 0.001) and CSM (HR 1.61, CI 95% 1.04-2.49, p < 0.03). The presence of TT in RCC patients represents a key risk factor for worse perioperative, as well as long-term renal function. Specifically, patients with TT harbor a significant and early estimated glomerular filtration rate (eGFR) decrease. However, despite TT patients show a greater eGFR decline after surgery, they retain acceptable renal function, which remains stable over time.

Intra-Abdominal Epithelioid Neoplasm With EWSR1::CREB Fusions Involving the Kidney: A Clinicopathologic and Molecular Characterization With an Emphasis on Differential Diagnosis

Soft tissue neoplasms, harboring fusions between EWSR1 and FUS with genes encoding CREB transcription factors family (ATF1, CREB1, and CREM), are an emerging heterogeneous group of mesenchymal tumors that differ significantly in morphology, immunophenotypes, and behavior. Recently, EWSR1/FUS::CREB fusions have been recognized to define a group of aggressive neoplasms of epithelioid morphology with multiple growth patterns and a striking predilection for mesothelial-lined cavities. These neoplasms presenting as a primary neoplasm of intra-abdominal visceral organs are rare, which could elicit a wide range of differential diagnoses because of their diverse morphologies and immunohistochemical profiles. We report 3 cases of intra-abdominal epithelioid neoplasms with EWSR1::CREB fusions involving the kidney. This study included 2 female patients and 1 male patient, with age at presentation ranging from 17 to 61 years (mean: 32 years). All the patients underwent radical nephrectomy without adjunctive therapies. Grossly, the tumors were large, and all were solitary masses with sizes ranging from 5.6 to 30.0 cm (mean: 14.5 cm). Histologically, the neoplasms showed infiltrating and indistinct borders and were composed predominantly of monomorphic round-to-epithelioid cells with variable amounts of pale-to-clear cytoplasm, arranged in cords, nests, and sheets and embedded in a sclerotic hyalinized stroma with variable lymphoid cuffing either intermixed or at the periphery. Notably, a hemangiopericytomatous growth pattern was commonly seen. Nuclear atypia was mild, and mitotic activity was scarce. Immunohistochemically, all 3 cases were at least focally positive for epithelial membrane antigen and keratin AE1/AE3, with 2 tumors showing focal MUC4 expression and 1 case displaying diffuse CD34 and focal CAIX positivity. Targeted RNA sequencing identified EWSR1::CREM fusion in 2 cases and EWSR1::ATF1 fusion in 1 case. Subsequent fluorescence in situ hybridization analysis confirmed the RNA sequencing results. On follow-up, 1 patient developed multiple spinal bone metastases 5 months after the surgery while the other 2 patients were free of disease 9 and 120 months after diagnosis, respectively. Our findings demonstrate that intra-abdominal epithelioid neoplasms with EWSR1::CREB fusions may rarely occur primarily in the kidney and should be included in the differential diagnosis of primary renal epithelioid mesenchymal neoplasms.

Functional outcomes of repeat kidney resection in patients with cancer recurrence after nephron-sparing surgeries

Aim. To perform comparative analysis of functional outcomes of repeat kidney resection and radical nephrectomy in patients with local cancer recurrence after previous organ-sparing surgeries.Materials and methods. Data on 64 patients who underwent surgical treatment at the Oncourology Department of the N.N. Blokhin National Medical Research Center of Oncology between 2000 and 2022 due to local kidney cancer recurrence after previous nephron-sparing surgeries were retrospectively and prospectively included in the study. Among these, 37 (57.8 %) patients underwent repeat kidney resection (treatment group) and 27 (42.2 %) patients underwent radical nephrectomy (control group). The groups were matched in demographic and clinical characteristics (р &gt;0.05). Median diameter of recurrent tumor in the treatment and control groups was 2.5 and 3.0 cm, respectively (95 % confidence interval 2.0–3.0 cm; Q1–Q3 2.4–4.0 cm). This difference was statistically significant (р = 0.012), but not clinically. Median follow-up duration was 35 (3–131) months (Q1–Q3 13–57 months).Results. Repeat nephron-sparing surgeries correlated with lower decrease in kidney function compared to organ-resecting surgical treatment. In the early postoperative period, decrease in calculated glomerular filtration rate per the CKD-EPI formula compared to baseline after re-resection and nephrectomy was 16 and 32 % (р = 0.010); long-term, it was 8 ± 41 and 45 ± 22 % (р &lt;0.001), respectively. Complication rates in the groups were similar: 21.6 and 29.6 %, respectively (р = 0.563).Conclusion. For local kidney cancer recurrence, repeat resection promotes preservation of kidney function without increased complication rate.

Examining the utility of routine perioperative hemoglobin monitoring in patients undergoing radical nephrectomy.

Patients undergoing radical nephrectomy (RN) are often admitted with protocolized bloodwork for several days following their operation, yet the clinical value of serial hemoglobin (Hgb) measurements has not been established. This can lead to unnecessary costs and can prolong patient stay, despite the absence of an intervention based on these lab values. This study sought to examine perioperative Hgb values and identify those patients at high risk of bleeding requiring intervention, as well as those patients who are unlikely to require further monitoring. Patient and perioperative factors were retrospectively examined for a cohort of 259 radical nephrectomy patients from 2015-2021 in Atlantic Canada. Postoperative Hgb values and transfusion rates were recorded. A multivariate logistic regression analysis was performed to identify variables associated with requiring a blood transfusion. Overall, 31 (12%) patients required a blood transfusion in the postoperative period. Median estimated blood loss (EBL) was 150 (interquartile range [IQR] 100-300) ml, with a median Hgb change of 15 (IQR 9-22) g/L from preoperative to postoperative day 1 (POD1). In patients with a Hgb loss of ≤15 g/L (n=131), transfusion was only required in four patients (3.1%). Among those with a POD1 Hgb >100 g/L (n=199), only four (2%) required transfusion. These patients were identified as having complications based on hemodynamic instability. On multivariate regression analysis, factors found to be associated with higher transfusion risk were age and intraoperative EBL, while higher preoperative Hgb was found to be associated with a lower transfusion risk. In patients who have a reassuring POD1 Hgb value, with a drop of <15 g/L or an absolute value of >100 g/L, consideration can be made towards discontinuing routine Hgb testing in the absence of a clinical indication. Age, blood loss, and preoperative Hgb are factors that may affect a patient's overall risk of transfusion.

Application of R.E.N.A.L Nephrometry Score in Planning Type of Surgery and Predicting Complications in RCC Patients in Gezira Hospital

Background: Adult renal cell carcinomas account for 80–85% of all renal tumors, making them the most common primary renal tumors. As a method for categorizing renal masses by anatomical characteristics, R.E.N.A.L score is suggested to study the effect on surgical approach in addition to perioperative outcomes and complications.&#x0D; Methods: A cross-sectional prospective hospital-based study enrolled 48 RCC patients in GHRDS in the period between September 2020 and September 2021. Data regarding demographics, histological subtypes, surgical approach, intraoperative and postoperative complications were collected. Based on R.E.N.A.L score, the complexity of renal tumors is grouped into low, moderate, and high.&#x0D; Results: The study sample size was 48. Twenty-five participants (52.1%) were men with a mean age of 51 years. Most cases had clear cell RCC 22 (45.8%) and papillary RCC 19 (39.6%). Thirty-nine (81.5%) patients underwent radical nephrectomy (flank incision [extraperitoneal] in 32 [82.1%] and midline incision [transperitoneal] in 7 [17.3%]), and 9 (18.5%) patients underwent partial nephrectomy. One-third of the patients 15 (31.2%) had intraoperative complications and 7 (14.6%) had postoperative complications. All intraoperative and most postoperative complications were associated with radical nephrectomy (P = 0.001). According to complexity, 21 (43.8%) patients had moderate complexity, 15 (31.2%) high complexity, and 12 (25%) low complexity.&#x0D; Conclusion: Most RCC patients had moderate complexity and were subjected to radical nephrectomy. High complexities were linked to the decision of radical nephrectomy, and intraoperative and postoperative complications. More prospective research with large sample size and multi-centered studies is essential to ensure the generalizability of study findings.

Surgical Trends and Complications in Partial and Radical Nephrectomy: Results from the GRAND Study.

We aimed to evaluate the current trends in renal cancer surgery, as well as to compare the perioperative outcomes of partial versus radical nephrectomy. We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2005-2021). We report the largest study in the field, with 317,843 patients and multiple patient-level analyses. Overall, 123,924 (39%) patients underwent partial and 193,919 (61%) underwent radical nephrectomy in Germany from 2005 to 2021. Of them, 57,308 (18%) were operated on in low-, 142,702 (45%) in intermediate-, and 117,833 (37%) in high-volume centers. A total of 249,333 (78%) patients underwent open, 44,994 (14%) laparoscopic, and 23,516 (8%) robotic nephrectomy. The number of patients undergoing renal surgery remained relatively stable from 2005 to 2021. Over the study period, the utilization of partial nephrectomy increased threefold, while radical nephrectomy decreased by about 40%. After adjusting for major risk factors in the multivariate regression analysis, radical nephrectomy was associated with 3.2-fold higher odds (95% CI: 3.2 to 3.9, p < 0.001) of 30-day mortality, longer hospitalization by 1.9 days (95% CI: 1.9 to 2, p < 0.001), and higher inpatient costs by EUR 1778 (95% CI: 1694 to 1862, p < 0.001) compared to partial nephrectomy. Furthermore, radical nephrectomy had a higher risk of in-hospital transfusion (p < 0.001), sepsis (p < 0.001), acute respiratory failure (p < 0.001), acute kidney disease (p < 0.001), acute thromboembolism (p < 0.001), surgical wound infection (p < 0.001), ileus (p < 0.001), intensive care unit admission (p < 0.001), and pancreatitis (p < 0.001). More patients are offered partial nephrectomy in Germany. Patients undergoing radical nephrectomy present with a higher rate of concomitant risk factors and have increased perioperative morbidity and mortality, prolonged hospitalization, and increased in-hospital costs.

Surgical Management and Oncologic Outcomes of Renal Cell Carcinoma and Inferior Vena Caval Thrombi With Aggressive Histologic Variants

To characterize the surgical management, perioperative, and cancer-specific outcomes, and the influence of aggressive histologic variants (AHV) on operative management among patients with renal cell carcinoma (RCC) and inferior vena cava (IVC) thrombus. RCC with rhabdoid and/or sarcomatoid differentiation, which we defined as AHV, portends a worse prognosis. AHV can be associated with a desmoplastic reaction which may complicate resection. We reviewed patients undergoing radical nephrectomy and IVC thrombectomy between 1990 and 2020. Comparative statistics were employed as appropriate. Survival analysis was performed according to the Kaplan-Meier method, and intergroup analysis performed with log-rank statistics. Multivariable cox proportional hazards regression was used to assess the effect of AHV, age, thrombus level, vena cavectomy, metastases, and medical comorbidities on recurrence and overall survival (OS). Ninety-four of 403 (23.3%) patients had AHV, including 43 (46%) rhabdoid, 39 (41%) sarcomatoid, and 12 (13%) with both. AHV were more likely to present with advanced disease; however, increased perioperative complications or decreased OS were not observed. Median (IQR) survival was 16.7 (4.8-47) months without AHV and 12.6 (4-29) months with AHV (P=.157). Sarcomatoid differentiation was independently associated with worse OS (HR=2.016, CI 1.38-2.95, P<.001), whereas rhabdoid alone or with sarcomatoid demonstrated similar OS (P=0.063). RCC and IVC thrombus with AHV are more likely to present with metastatic disease, and sarcomatoid differentiation is associated with a worse OS. Resection of tumors with and without AHV have similar perioperative complications, suggesting that surgery can be safely accomplished in patients with RCC and IVC thrombus with AHV.

OR02-05 Differences In Genomic Characteristics Of Small Aldosterone-producing Lesions Between Normal And Pathologic Adrenals

Abstract Disclosure: J. Lim: None. S. Plaska: None. &amp;. Liu: None. J. Baker: None. A. Blinder: None. W.E. Rainey: None. A.M. Udager: None. Introduction: Primary aldosteronism (PA) – the most common form of secondary hypertension – is characterized by inappropriate adrenal aldosterone production under suppressed renin conditions. The majority of PA is caused by unilateral aldosterone-producing adenomas (APA) and bilateral hyperaldosteronism (BHA). Emerging evidence suggests that BHA is associated with the accumulation of small aldosterone-producing lesions (less than 1 cm in diameter), including aldosterone-producing micronodules (APM) and/or aldosterone-producing nodules (APN). However, previous studies have shown that APM may also be observed in normal adrenals, and thus, the impact of APM and APN on the development and progression of aldosterone overproduction is not well established. In this study, we compare the frequency and distribution of somatic aldosterone-driver mutations in small aldosterone-producing lesions from normal and pathologic adrenals. Methods: Twenty-eight normal adrenals from deceased renal donors (n=24) and patients undergoing radical nephrectomy for renal cell carcinoma (n=4) were compared with 24 pathologic adrenals from patients with PA who underwent adrenalectomy at the University of Michigan. CYP11B2 immunohistochemistry-guided capture was performed to selectively obtain APM and APN DNA from formalin-fixed paraffin embedded tissue, and mutation status for all known aldosterone-driver genes was determined by Ion Torrent-based targeted next-generation sequencing. Results: From normal adrenals, 57 APM from 12 female and 16 male subjects (median age = 49 years) were analyzed, and approximately 46% of these lesions harbored an aldosterone-driver mutation. The most commonly mutated gene in normal samples was CACNA1D (n = 23; 40.4%), but no KCNJ5 mutations were identified, and no significant sex differences were observed. From pathologic adrenals, 56 APM and 7 APN from 17 female and 7 male subjects (median age = 46.5 years) were analyzed, and the frequency of aldosterone-driver mutations (approximately 70%) was significantly higher than normal adrenals (p-value &amp;lt; 0.05). Although CACNA1D mutations were still predominant in pathologic adrenals (n = 33; 52.4%), a number of KCNJ5 mutations were also observed (n = 5; 7.9%) – particularly in APN. Finally, there was a higher rate of aldosterone-driver mutations in small aldosterone-producing lesions in pathologic adrenals from men compared to women (93.3% vs. 62.5%; p-value = 0.051). Conclusions: The frequency and distribution of aldosterone-driver mutations in small aldosterone-producing lesions (APM and APN) in pathologic adrenals are different from those in normal adrenals and may also vary by sex. Further research is needed on how these different APM patterns affect autonomous aldosterone production in patients with PA. Presentation: Thursday, June 15, 2023

The effect of antiplatelet therapy on outcomes in patients who underwent laparoscopic radical nephrectomy: A Japanese single-center study.

The number of patients receiving antiplatelet therapy (APT) who have undergone laparoscopic radical nephrectomy is increasing. However, it is unclear whether APT affects the outcomes of patients undergoing radical nephrectomy. We investigated the perioperative outcomes of radical nephrectomy in patients with and without APT. We retrospectively collected data from 89 Japanese patients who underwent laparoscopic radical nephrectomy for clinically diagnosed renal cell carcinoma (RCC) at Kokura Memorial Hospital between March 2013 and March 2022. We analyzed information related to APT. We divided the patients into two groups: the APT group (patients receiving APT) and the N-APT group (patients not receiving APT). Moreover, the APT group was further divided into the C-APT group (patients with continuous APT) and the I-APT group (patients with interrupted APT). We compared the surgical outcomes of these groups. Among 89 patients eligible for the study, 25 received APT and 10 continued APT. Even though the patients who received APT had a high American Society of Anesthesiologists physical status and many complications, including smoking, diabetes, hypertension, and chronic heart failure, no significant difference in the intra- or postoperative outcomes, including bleeding complications, was observed regardless of whether the patients received APT or continued APT. We concluded that in laparoscopic radical nephrectomy, continuation of APT is an acceptable strategy for patients with thromboembolic risk caused by interruption of APT.

Thyroid-like follicular carcinoma of kidney

Abstract Renal cancer resembling thyroid-like tumor of the kidney is extremely rare. This type of renal tumor shows the morphologic features that resemble follicular carcinoma of thyroid. In our case, a 62-year-male patient presented with flank pain with all blood parameters in normal range. Chest X-ray were normal, contrast enhanced computed tomography report showed well defined hyperdense lesion of size 26 mm × 21 mm showing homogenous enhancement (hu 46–126 from pre to post contrast) noted in lower pole of right kidney. Patient underwent radical nephrectomy, histopathological examination suggestive of thyroid-like follicular carcinoma with IHC markers as TTF1-negative, CK7-negative, and PAX8-negative. Patient was referred to Department of Radiotherapy for further management. Immunohistochemical staining studies in the literatures showed that this tumor consistently expressed the transcription factor PAX-8 but did not express the thyroid-specific antibodies TG and TTF-1. Most tumors with diameters of more than 4 cm or associated with invasive growth or distant metastasis are treated mainly with radical nephrectomy, combined with the corresponding regional lymph node dissection. Surgical treatment is still the preferred therapeutic method. The disease seems to have a good prognosis.

MP58-13 FUNCTIONAL OUTCOMES AFTER SURGERY IN PATIENTS WITH RENAL CANCER AND TUMOR THROMBUS

MP58-13 FUNCTIONAL OUTCOMES AFTER SURGERY IN PATIENTS WITH RENAL CANCER AND TUMOR THROMBUS

PD17-09 CD70-POSITIVE EXTRACELLULAR VESICLES FOR DETECTION OF CLEAR-CELL RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 Apr 2023PD17-09 CD70-POSITIVE EXTRACELLULAR VESICLES FOR DETECTION OF CLEAR-CELL RENAL CELL CARCINOMA Rodrigo R. Pessoa, Reza Nabavizadeh, Ali Arafa, Roxane Lavoie, Yohan Kim, Liguo Wang, Jeanette Eckel-Passow, Bradley C. Leibovich, and Fabrice Lucien Rodrigo R. PessoaRodrigo R. Pessoa More articles by this author , Reza NabavizadehReza Nabavizadeh More articles by this author , Ali ArafaAli Arafa More articles by this author , Roxane LavoieRoxane Lavoie More articles by this author , Yohan KimYohan Kim More articles by this author , Liguo WangLiguo Wang More articles by this author , Jeanette Eckel-PassowJeanette Eckel-Passow More articles by this author , Bradley C. LeibovichBradley C. Leibovich More articles by this author , and Fabrice LucienFabrice Lucien More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003272.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: One third of patients treated for localized clear-cell renal cell carcinoma (ccRCC) will eventually develop recurrent disease after surgery. Identification of patients who may benefit from intensification of care with adjuvant therapy is an important unmet need. Tumor-derived extracellular vesicles (EVs), microscopic particles released by tumor cells, have emerged as a potential biomarker in other malignancies but have not been studied in kidney cancer. Herein, we sought to characterize tumor specific EVs levels among patients undergoing radical nephrectomy for ccRCC. METHODS: We employed in silico multi-omic analysis of ccRCC tumors using TCGA KIRC (N=537 patients), CPTAC (N= 103 patients) and GTEx (N= 948 donors) to identify CD70, an integral membrane protein, as the top marker candidate for ccRCC-derived EVs. Expression of CD70+ in ccRCC-derived EVs was confirmed using freshly isolated tumor specimens. Blood levels of circulating CD70+-EVs were measured using high resolution flow cytometry in a cohort of age-matched healthy donors (HD) (N=15) and ccRCC patients (N=29) treated with radical nephrectomy. EVs levels between HD and RCC patients were compared using ANOVA test. Association between patient characteristics and EVs levels was analyzed using Pearson’s correlation and Fisher’s exact test. RESULTS: Blood levels of CD70+-EVs were significantly elevated in patients with pT1-T2 (median: 4.3×106 per mL, p<0.01) and pT3-T4 (median: 6.0×106, p<0.001) ccRCC compared with HD (median: 0.4×106, Figure 1A). High CD70+-EVs levels were associated with pT3-T4 stage (Figure 1B, p<0.0001).There was a strong positive correlation between CD70+-EVs at diagnosis and tumor size (Pearson r=0.76, p<0.0001, Figure 1C). Radical nephrectomy was associated with reduction in CD70+-EVs levels in 83.8% of patients (Figure 1D, p=0.0076). CONCLUSIONS: Patients with ccRCC, in particular those with larger and more advanced stage tumors, have high levels of circulating CD70+-EVs, which decreases significantly after surgery. CD70+-EVs levels are a marker of tumor burden in ccRCC and could be further explored as a biomarker for risk-stratification and selection of patients for additional treatment after radical nephrectomy for ccRCC. Source of Funding: Eagles 5th District Cancer Telethon - Cancer Research Fund (FL) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e499 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rodrigo R. Pessoa More articles by this author Reza Nabavizadeh More articles by this author Ali Arafa More articles by this author Roxane Lavoie More articles by this author Yohan Kim More articles by this author Liguo Wang More articles by this author Jeanette Eckel-Passow More articles by this author Bradley C. Leibovich More articles by this author Fabrice Lucien More articles by this author Expand All Advertisement PDF downloadLoading ...

PD40-10 THE IMPACT OF FRAILTY ON PERIOPERATIVE OUTCOMES IN PATIENTS UNDERGOING RADICAL NEPHRECTOMY

You have accessJournal of UrologyCME1 Apr 2023PD40-10 THE IMPACT OF FRAILTY ON PERIOPERATIVE OUTCOMES IN PATIENTS UNDERGOING RADICAL NEPHRECTOMY Rahul Dutta, Justin Refugia, Ethan Matz, Randy Casals, and Matvey Tsivian Rahul DuttaRahul Dutta More articles by this author , Justin RefugiaJustin Refugia More articles by this author , Ethan MatzEthan Matz More articles by this author , Randy CasalsRandy Casals More articles by this author , and Matvey TsivianMatvey Tsivian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003345.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: As the geriatric population continues to grow, an increasing number of medically frail patients are developing renal masses that necessitate surgical intervention. These patients, however, are significantly more likely to suffer from adverse events following a variety of surgical procedures. We sought to better understand the relationship with frailty and postoperative complications after open (ORN) and laparoscopic (LRN) radical nephrectomy for renal masses. METHODS: The National Surgical Quality Improvement Program database was queried for ORN (CPT® 50230) and LRN (CPT® 50545) from 2015-2020. The modified 5-item frailty index (5-MFI) was calculated based on patient functional status and medical comorbidities (diabetes, congestive heart failure, chronic obstructive pulmonary disease, and hypertension requiring medication). Patients with a 5-MFI score ≥2 were considered medically frail. Associations with 30-day events were analyzed. RESULTS: A total of 6,324 ORN and 15,629 LRN were included, of which 22% and 24%, respectively, were considered frail by at 5-MFI score of ≥2. Increased age and body mass index (BMI) were significantly associated with frailty for both ORN and LRN (p<0.05). Upon multivariate analysis controlling for age and BMI in ORN, frailty was independently associated with minor (OR=1.17 [1.03-1.33], p=0.013) and major (OR=1.43 [1.16-1.77], p=0.001) postoperative complications. Both repeat operations (OR=1.56 [1.08-2.25], p=0.018) and readmissions (OR=1.39 [1.12-1.71], p=0.002) were also independently associated with frailty. Similarly for LRN, minor complications (OR=1.75 [1.56-1.98], p<0.001), major complications (OR=1.74 [1.45-2.08], p<0.001) and readmissions (OR=1.62 [1.39-1.90], p<0.001) were independently associated with frailty; reoperations (OR=1.10 [0.82-1.47], p=0.526) were not. CONCLUSIONS: Patients considered medically frail are more likely to suffer from 30-day postoperative complications, unplanned readmissions, and reoperations following radical nephrectomy. In the context of an aging population, frailty should be taken into consideration for counseling and postoperative management following radical nephrectomy. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1056 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rahul Dutta More articles by this author Justin Refugia More articles by this author Ethan Matz More articles by this author Randy Casals More articles by this author Matvey Tsivian More articles by this author Expand All Advertisement PDF downloadLoading ...

Validating the Palacios’ future glomerular filtration rate equation with and without race.

616 Background: Accurate prediction of future glomerular function rate (fGFR) following nephrectomy in renal cell carcinoma (RCC) patients is of interest. A postoperative estimated glomerular filtration (eGFR) rate ≥ 45 mL/min/1.73m2 is considered favorable, with guidelines reflecting these findings. Though nephron sparing surgery is preferable, radical nephrectomy is often the preferred oncologic surgery. Various models to predict postoperative renal function have been proposed, with a new 2021 equation by Palacios et al. exhibiting strong performance in predicting fGFR. We aim to validate this fGFR equation in a large institutional cohort using both the Chronic Kidney Disease Epidemiology (CKD-EPI) 2009 equation with race, used in the creation of the formula, as well as the CKD-EPI 2021 equation without race, which is currently the recommended CKD-EPI creatinine equation. Methods: Using an institutional database, patients that underwent partial or radical nephrectomy for RCC from 2005-2021 were identified. Patients with creatinine values preoperatively and 3-12 months postoperatively were included, with end stage renal disease serving as exclusion criteria. Correlation/bias/accuracy/precision of the fGFR equation (fGFR=35+ [preoperative eGFR x 0.65]- 18 [if radical] - [age x 0.25]+ 3 [if tumor &gt;7cm]-2 [if diabetes]) with observed postoperative eGFR was determined by both the CKD-EPI-2021 and CKD-EPI 2009 equations. Results: 1,443 patients were included in our analysis. 71% (1,024) and 22.9% (331) patients were white and black, respectively. A majority of patients underwent radical nephrectomy (60.3%). 40% of patients had T3-T4 RCC, with 14.8% of patients having M1 disease. Median observed vs predicted fGFR was 58.0 vs 58.7 ml/min/1.73m2 for CKD-EPI 2021 and 56.0 vs 57.5 for CKD-EPI 2009. The correlation/bias/accuracy/precision of the fGFR equation was 0.805/-0.5/81.7/7.9-9.0 for CKD-EPI 2021 and 0.809/-0.8/81.3/-8.1-8 for CKD-EPI 2009 equations (Table). Conclusions: The fGFR equation accurately predicted renal function in our large and diverse institutional cohort using both the CKD-EPI 2009 including race and CKD-EPI 2021 excluding race equations. [Table: see text]

Readmissions after radical nephrectomy in a national cohort

Objective To analyze the factors and costs associated with 30-day readmissions for patients undergoing radical nephrectomy. Materials and Methods We used the 2014 Nationwide Readmission Database to identify adults who underwent radical nephrectomy for renal cancer, stratified by surgical approach. We determined patient factors associated with readmission rates, diagnoses, and costs using multivariate logistic regression. Results Among 19,523 individuals, the 30-day readmission rate was 7.7% (n = 1,506). On multivariate regression, odds of readmission were significantly increased with age ≥75 in those who underwent open nephrectomy (OR: 1.35; 95%CI: 1.03–1.78). Subjects with a Charlson comorbidity score ≥3 had significantly higher rates of readmission regardless of surgical approach (Open RN – OR: 1.85; 95%CI: 1.33–2.56; Lap RN – OR: 1.99; 95%CI 1.10–3.59; Robotic RN – OR: 2.18; 95%CI: 1.23–3.86). Common reasons for readmission were gastrointestinal, cardiovascular, urinary tract infections, and wound complications across all surgical approaches. The mean cost per readmission was as high as 126% ($20,357) of the mean index admission cost. Conclusion One in 13 adults undergoing radical nephrectomy is readmitted within 30 days of discharge. Associated readmission cost is up to 1.26 times the cost of index admission. Our findings may inform efforts aiming to reduce hospital readmissions and curtail healthcare costs.

Survival analysis and predictors of long-term outcomes following radical nephrectomy with inferior vena cava (IVC) thrombectomy in renal cell carcinoma.

Renal cell carcinoma (RCC) presents with inferior vena cava (IVC) thrombus in 10%-30% cases and surgical management forms the mainstay of the treatment. The objective of this study is to assess the outcomes of the patients undergoing radical nephrectomy with IVC thrombectomy. A retrospective analysis of patients undergoing open radical nephrectomy with IVC thrombectomy between 2006 till 2018 was done. A total of 56 patients were included. The mean (±standard deviation) age was 57.1 (±12.2) years. The number of patients with levels I, II, III, and IV thrombus were 4, 29,10, and 13, respectively. The mean blood loss was 1851.8 mL, and the mean operative time was 303.3 minutes. Overall, the complication rate was 51.7%, while the perioperative mortality rate was 8.9%. The mean duration of hospital stay was 10.6 ± 6.4 days. The majority of the patients had clear cell carcinoma (87.5%). There was a significant association between grade and stage of thrombus (P = 0.011). Using Kaplan-Meier survival analysis, the median overall survival (OS) was 75 (95% confidence interval [CI] = 43.5-106.5) months, and the median recurrence-free survival (RFS) was 48 (95% CI = 33.1-62.3) months. Age (P = 0.03), presence of systemic symptoms (P = 0.01), radiological size (P = 0.04), histopathological grade (P = 0.01), level of thrombus (P = 0.04), and invasion of thrombus into IVC wall (P = 0.01) were found to be significant predictors of OS. The management of RCC with IVC thrombus poses a major surgical challenge. Experience of a center along with high-volume and multidisciplinary facility particularly cardiothoracic facility provides better perioperative outcome. Though surgically challenging, it offers good overall-survival and recurrence-free survival.