Radical Nephrectomy For Renal Mass Research Articles

External oblique intercostal block in open nephrectomy patients - A zenith in analgesia for anterolateral upper abdominal surgeries: A case series

Open nephrectomy is a common surgery usually performed for malignant and non-malignant renal pathologies. The external oblique intercostal block (EOIB) blocks the anterior and lateral cutaneous nerves from T6 to T10 and provides somatic analgesia. We present a case series of the use of EOIB in patients undergoing open nephrectomy by subcostal incision. Ten patients were given EOIB, which included patients undergoing simple nephrectomy for non-functioning kidneys and radical nephrectomy for renal mass. The patients had satisfactory numerical rating scale scores, mostly <4 for 24 h. Post-operative opioid consumption was minimal. The external oblique fascial plain block is a novel thoracic block that provides reliable upper thoracoabdominal somatic analgesia. It can certainly be considered a suitable option in surgeries such as nephrectomies that involve an upper lateral abdominal wall incision.

Chromophobe renal cell carcinoma with rare distant metastasis.

Metastasis accounts for the most common tumor of the central nervous system (CNS) in adults. Renal cell carcinoma (RCC) is one of the common carcinoma showing brain metastasis, with a predilection for clear cell variant. Chromophobe RCC (ChRCC) in contrast to clear cell RCC shows far less common distant metastasis. When they metastasize, commonly involve the liver, lungs, and lymph nodes. ChRCC metastasizing to the brain is extremely rare. Isolated brain metastasis from RCCs is also uncommon. We report an unusual case of a 54-year-old woman with ChRCC with isolated metastasis to the brain, 2 years after radical nephrectomy for renal mass.

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 ...

Perioperative Outcomes of Laparoscopic Radical Nephrectomy for Renal Mass in Patients on Dialysis or with Renal Transplant in Place Compared to Normal Controls.

Background: The risk of renal cell carcinoma (RCC) development in the native kidney of patients on dialysis or with a renal transplant is increased compared to the general population. This study examines perioperative outcomes of laparoscopic radical nephrectomy (LN) in dialysis patients or renal transplant patients compared to normal controls. Methods: Four hundred twelve consecutive LN were evaluated (July 2007 to October 2018). Patients were divided into three groups (control, dialysis, and transplant). Perioperative outcomes, including operating room time (OT), postoperative complications, hospital length of stay, and 90-day readmission rates, were evaluated for the three groups. Results: There were 62 patients in the dialysis group, 20 renal transplants, and 330 normal controls. Dialysis patients were younger (median: 58 years versus 67 years; P = .002) and predominantly male (73% versus 59%, P = .047). Dialysis patients compared to controls had shorter total OT (median: 133 versus 149; P = .022), more papillary RCC (27% versus 10%; P < .001), and fewer high grade tumors (73% [8/11] versus 94% [100/106]; P = .038). Renal transplant patients had a higher rate of 90-day readmission (20% versus 6%; P = .034) and more papillary RCC (30% versus 10%; P = .016) compared to controls. Conclusion: LN on dialysis patients does not alter expected perioperative outcomes compared to a large cohort of control LN. LN on renal transplant patients carries a higher 90-day readmission rate than control LN.

The Platelecrit: The Role in Differential Diagnosis of Small Renal Masses

Objective: To evaluate the importance of preoperative plateletcrit value predicting malignancy in patients who undergo open surgery due to small renal masses. Material and methods: Sixty-eight patients who underwent open partial or radical nephrectomy for renal masses were included in this retrospective study. In preoperative routine blood tests, renal ultrasonography and contrast-enhanced computed tomography were performed for all patients. Preoperative plateletcrit values were compared in patients with clear cell renal cell carcinoma (Group 1, 57 patients) and benign lesions (Group 2, 11 patients). The predictive ability of plateletcrit was analyzed by ROC-curves and Youden Index method was used to identify the cut-off value for plateletcrit. Results: The mean age of patients was 57.33±8.65 years in Group 1 and 59.32±10.59 years in Group 2 (p=0.546). The mean tumor size was 31.1 ± 5.84 mm in Group 1 and 28.07 ±6.25 mm in Group 2 (p=0.132). The median plateletcrit value was 1858,21 ±268,49 in Group 1 and 2258,01±524,35 in Group 2 (p:0.017). The area under a ROC-curve was 0.756 (p<0.05) . Conclusion: Preoperative plateletcrit values may predict renal masses that can not be distinguished radiologically. Our results must be confirmed by large and properly designed prospective, randomized trials.

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

Outcomes and predictors of benign histology in patients undergoing robotic partial or radical nephrectomy for renal masses: a multicenter study.

IntroductionTheaim of this study was to assess preoperative factors associated with benign histology in patients undergoing surgical removal of a renal mass and to analyze outcomes of robotic partial nephrectomy (PN) and radical nephrectomy (RN) for these masses.Material and methodsOverall, 2,944 cases (543 benign and 2,401 malignant) who underwent robotic PN and RN between 2003–2018 at 10 institutions worldwide were included. The assessment of the predictors of benign histology was made at the final surgical pathology report. Descriptive statistics, Mann-Whitney U, Pearson’s χ2, and logistic regression analysis were used.ResultsPatients in the benign group were mostly female (61 vs. 33%; p <0.001), with lower body mass index (BMI) (26.0 vs. 27.1 kg/m2; p <0.001). The benign group presented smaller tumor size (2.8 vs. 3.5 cm; p <0.001), R.E.N.A.L. score (6.0 vs. 7.0; p <0.001). There was a lower rate of hilar (11 vs.18%; p = 0.001), cT≥3 (1 vs. 4.5%; p <0.001) tumors in the benign group. There was a statistically significant higher rate of PN in the benign group (97 vs. 86%; p <0.001) as well as a statistically significant lower 30-day re-admission rate (2 vs. 5%; p = 0.081). Multivariable analysis showed male gender (OR: 0.52; p <0.001), BMI (OR: 0.95; p <0.001), and cT3a (OR: 0.22; p = 0.005) to be inversely associated to benign histology.ConclusionsIn 18% of cases, a benign histologic type was found. Only 3% of these tumors were treated with RN. Female gender, lower BMI, and higher T staging showed to be independent predictors of benign histology.

1867 A Case of Mistaken Identities: Impact of Kayexalate on the Colon

INTRODUCTION: End stage renal disease (ESRD) affects nearly 750,000 Americans each year. Kayexalate (sodium polystyrene sulfonate) is commonly used to manage hyperkalemia in ESRD. Kayexalate is a nonspecific cation exchange resin that acts in the large intestine to allow for the exchange of sodium for any cation (potassium, calcium or magnesium). Kayexalate has an inherent lattice structure. Addition of calcium ions can lead to crystal formation that appears basophilic, rhomboid/triangular with a fish-scale appearance on Hematoxylin and Eosin (H&amp;E) stain. Studies show that the combination of kayexalate and sorbitol, an osmotic laxative, may lead to osmotic shifts and ischemic damage. However, the impact of kayexalate alone in gastrointestinal tract is less established. We present a case of kayexlate crystal deposition appearing as a pseudo-polyp in the appendiceal orifice. CASE DESCRIPTION/METHODS: A 51-year-old woman with a past medical history significant for systemic lupus erythematosus, radical nephrectomy for renal mass complicated by dialysis dependent ESRD, mitral and aortic valve replacement on Coumadin, presented to the hospital for hyperkalemia requiring emergent dialysis. The patient developed melena in the setting of supratherapeutic INR. Colonoscopy revealed a non-obstructing 10mm yellow mass protruding from, and tethered to, the appendiceal orifice. The pseudo-polyp appeared to be on a stalk. Resection was performed using a biopsy forceps at the base. Pathology revealed foreign crystalline material that was suggestive of kayexalate deposition. The source of gastrointestinal bleeding was later identified as a jejunal arteriovenous malformation. DISCUSSION: Reports of kayexalate effects on the gastrointestinal tract are somewhat limited, but include findings of acute inflammatory tissue injury in as early as 24 hours, potentially with colonic ulceration. Kayexalate can also cause mechanical obstruction secondary to the development of crystalline structures in the colon. Prolonged uses of this medication can likewise lead to reversible crystal deposition within the esophagus, stomach and duodenum. This case highlights the potential for crystal resin deposition to appear as a pseudopolyp. Gastroenterologists should carefully review medication history when approaching a patient with a mechanical obstruction or colon ulceration in the setting of ESRD.

The impact of neutrophil-to-lymphocyte, platelet-to-lymphocyte and haemoglobin-to-platelet ratio on localised renal cell carcinoma oncologic outcomes

The neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR) are established markers of systemic inflammation. Moreover, anemia is a known adverse prognostic factor and reduced haemoglobin to platelet ratio (HPR) seems associate to poor outcomes in urothelial cancer. Aim of the current study was to explore the prognostic value of NLR, HPR and PLR in patients harboring localized RCC. Materials and Methods 184 patients undergoing partial and radical nephrectomy for renal mass in a single hospital were retrospectively analyzed. Uni- and multivariate logistic regressions were performed to assess associations between various risk factors, including NLR, PLR and HPR and locally advanced disease (≤pT2 vs.≥pT3) and tumor grade. Kaplan Meier curves and Cox regressions were constructed to assess the association of NLR, PLR and HPR to recurrence free survival (RFS), cancer specific survival (CSS) and overall survival (OS). To determine thresholds for variables, we considered the 75th percentile of our distribution of values, which was computed at 3.45 for NLR, 189 for PLR and 0.48 for HPR. A two-sided P<0.05 defined statistical significance. Patients with an elevated NLR (>3.45) were more likely to present with≥pT3 stage (p=0.046). RFS was significantly different according to NLR value, with patients having an NLR>3.45 experiencing significantly worst RFS (P=0.019); similarly, an increased PLR was significantly associated to a reduced RFS (P=0.012). Restricting the Cox regression to patients with locally advanced disease (≥pT3), NLR was even more associated to recurrence (HR 3.22; 95%CI: 1.06-9.81, P=0.039). Patients exhibiting an NLR>3.45 (p=0.03) or a PLR>189 (P=0.005) did have a significantly worse CSS, while a HPR<0.48 did not predict CSS (P=0.12) on Kaplan Meier curves. Finally, an increased NLR (P=0.047), increased PLR (P=0.0006) and decreased HPR (P=0.05) were all associated to a poor overall survival on univariate analysis. On multivariate analysis, only HPR remained significantly predictive of OS (HR 0.077; 95%CI: 0.02-0.37, P=0.001). In this single-center study analyzing non-metastatic RCC, an increased NLR was significantly associated to a reduced RFS, CSS and OS on univariate analyses and to RFS on multivariate analysis. Larger prospective studies are needed to validate our findings. 4.

Laparoscopic Transperitoneal Radical Nephrectomy for Renal Masses with Level I and II Thrombus.

We aimed to report surgical and oncological outcomes of renal cell carcinoma (RCC) patients with level I and II thrombus treated with laparoscopic transperitoneal radical nephrectomy. Medical records of 13 patients were reviewed retrospectively in a single center between 2005 and 2017. Hem-o-lok® clips were used to secure renal artery and renal vein, excluding 2 patients with an attached thrombus on the right side. Seven male and 6 female patients were treated laparoscopically, and conversion to open surgery was not required in any case. The mean age was 61.6 ± 7.8 years (range 45 to 75 years) and the mean body mass index was 27 ± 4.6 kg/m2 (range 18.8 to 34.5 kg/m2). Median tumor size was 9.5 × 7.3 cm (range 5 to 14 cm) and 5 patients who had preoperative metastases underwent cytoreductive nephrectomy. The mean operative time was 137.6 ± 45.8 minutes (range 60 to 200 minutes) and blood loss was 105 ± 34.9 mL (range 50 to 150 mL). The mean hospital stay was 4.4 ± 3.9 days (range 1 to 15 days). Splenic capsular injury occurred in 1 patient and the vena cava was injured in another. Three patients needed blood transfusions. The mean follow-up period was 25 months (range 12 to 86 months). Laparoscopic transperitoneal radical nephrectomy can be reliable option for surgical management of RCC with level I and II thrombus in experienced centers.

1043 - Partial vs radical nephrectomy for renal masses in the octogenarian

1043 - Partial vs radical nephrectomy for renal masses in the octogenarian

Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015

Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown. To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy. This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes. Robotic-assisted vs laparoscopic radical nephrectomy. The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost. Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, -1.2%; 95% CI, -5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, -0.3%; 95% CI, -1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498). Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.

Persistent cough as a paraneoplastic presenting symptom in six patients with renal cell carcinoma

ObjectiveWith today's modern imaging modalities, patients diagnosed with renal cell carcinoma (RCC) rarely present symptomatically. In some cases, however, they can develop paraneoplastic syndromes with associated symptoms. To date, only three cases of RCC presenting with chronic dry cough have been reported. We describe six patients who presented with cough that improved following radical nephrectomy. MethodsA retrospective review of patients undergoing partial or radical nephrectomy for renal masses between January 2015 and March 2016 was performed, and patients presenting with a cough were examined. ResultsSix patients presented with chronic cough and were discovered to have a large renal mass. Postoperative spontaneous resolution of cough was noted in all but one patient, in whom coughing was reduced and limited to the mornings. Cough duration ranged from 3 months to just over a year. All patients were treated with radical nephrectomy, which was cytoreductive in four patients. Average tumor size was 10.9 cm (SD = 2.2 cm). Five of the tumors had clear cell pathology, and every tumor was Fuhrman grade IV, unifocal, and demonstrated necrosis. Sarcomatoid features were reported in four of the tumors. ConclusionOur study presents the largest series of patients with RCC who presented with a chronic cough that was significantly improved following radical nephrectomy. We believe the cause of cough is multifactorial and further investigation is needed to clearly elucidate the etiology.

Partial Nephrectomy for Small Renal Masses: Do Teaching and Nonteaching Institutions Adhere to Guidelines Equally?

The American Urological Association (AUA) guidelines recommend partial nephrectomy (PN) as the gold standard for treatment of small renal masses (SRMs). This study examines the change in utilization of partial and radical nephrectomies at teaching and nonteaching institutions from 2003 to 2012. The data sample for this study came from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2003 to 2012. International Classification of Diseases, Ninth Revision and Clinical Modification codes were used to identify patients undergoing PN and radical nephrectomy for renal masses limited to the renal parenchyma. Teaching hospitals were defined, but not limited to any institution with an American Medical Association-approved residency program. Linear regression, bivariate, multivariate, and odds ratio analysis were used to demonstrate statistical significance. 39,685 patients were identified in teaching hospitals, and 22,239 were identified in nonteaching hospitals. Prior to the 2009 AUA guidelines, cumulative rates of PN were 33% vs 20% in teaching vs nonteaching hospitals (p < 0.0001) compared with postguideline rates of 48% vs 33% in teaching vs nonteaching hospitals (p < 0.0001). During the 10-year study period, the use of PN to treat SRMs has significantly increased in both teaching hospitals and in nonacademic centers; however, these changes are occurring at a slower rate in nonteaching hospitals.

Nephron-Sparing Surgery

Renal cell carcinoma (RCC) is a common malignancy with an increasing incidence.1 2 The classic triad of abdominal mass, hematuria, and flank pain accompanied by the various associated paraneoplastic syndromes (or the “internist's tumor”) are rare presentations of contemporary kidney cancer. With the current use and practice of modern abdominal imaging, more than half of all renal tumors are incidentally discovered at a low stage during evaluation for other conditions. The renal mass has become increasingly amenable to treatment given this stage migration. Therefore, in the modern era, it might be more appropriate to refer to RCC as the “radiologist's tumor” rather than the internists. The International Union Against Cancer staging system for RCC defines a stage 1 renal mass as an organ-confined tumor up to 4.0 cm in diameter (T1a), and between 4.1 and 7.0 cm in diameter (T1b). The American Urological Association (AUA) published guidelines for the management of stage 1 renal mass in 2009 and had validity confirmed in 2010.3 The AUA's thorough review is a must read for any practitioner treating renal masses. The National Comprehensive Cancer Network (NCCN) also provides guidance on the management of stage 1 renal masses.4 In this review, a small renal mass (SRM) is considered a T1a renal mass. The majority of SRMs will be RCCs; however many, approximately 20% will have benign histology.5 Even many of those classified as kidney cancer may have an indolent clinical course with limited growth and low risk of metastasis.6 Malignant potential is an important consideration when contemplating the permanent removal of a renal unit. Stage 1 renal masses are often successfully treated with nephron-sparing surgery (NSS) and this is the preferred approach to the resectable SRM. For this article, NSS will include only surgical partial nephrectomy, but ablative therapies such as cryoablation and radiofrequency ablation are also successfully used to preserve renal tissue on an ipsilateral renal unit. NSS was proven feasible decades ago for patients with imperative indications to preserve maximum kidney function, for instance solitary kidney, bilateral renal tumors, or moderate/severe chronic kidney disease (CKD).7 This allowed for expansion of NSS into general use for the stage 1 renal mass. Pathologic studies have shown underlying renal disease is commonly present in presumably “normal” kidneys, and outcomes studies clearly demonstrate new CKD development after nephrectomy.8 CKD has been linked to cardiovascular disease, hospitalization, and death in a population-based study of more than 1 million patients.9 This study challenges the notion that the loss of a renal unit does not significantly impact long-term health outcomes. Unfortunately NSS is widely underutilized. An evaluation of a nationwide hospital database determined only 9% of patients with surgically treatable renal tumors were treated with NSS.7 There are varied reasons for the underuse of NSS; the complexity of the surgical endeavor, an under appreciation for the impact of radical nephrectomy (RN) on health outcomes, and peculiar financial incentives seem to contribute to underutilization. NSS does have more short-term complications compared with total nephrectomy, and the oncologic efficacy had not been proven in a randomized trial. Starting in 1992, the European Organization for Research and Treatment of Cancer (EORTC) attempted to perform a randomized trial of elective NSS and RN for renal masses 5 cm or smaller10; however, the study closed early due to poor accrual and has raised many statistical questions. The published data, however, should be carefully considered, and one safe conclusion from the trial is that both RN and NSS provide excellent oncologic control. There were more local recurrences (albeit few in total) in the NSS group.

Clinicopathological characteristics and outcomes of surgically excised renal masses in African Americans

ObjectivesIn the present study, we report on the clinical and pathological characteristics of African American (AA) patients with surgically excised renal masses and assess the associations between race and oncological outcomes. Methods and materialsWe conducted a retrospective review of patients who underwent partial or radical nephrectomy for renal masses at our institution between 2000 and 2010. Patients were divided into 2 groups based on self-reported race: AA and non-AA. Patient demographics and disease characteristics, and overall, cancer-specific, recurrence-free, distant, and local recurrence-free survival for localized renal cell carcinoma (RCC) were compared between AA and non-AA patients. Multivariable proportional hazard analyses were used to assess the associations of race with oncological outcomes. ResultsA total of 1,467 patients, of whom 359 (24.5%) were AA, were included. Rates of benign disease were comparable between AA patients and non-AA (18.2% vs. 17.6%, P = 0.556). AA patients presented with higher rates of localized disease (83% vs. 71%, P<0.001). Papillary subtype accounted for 40.8% of RCCs in AA patients compared with 11.6% in non-AA patients (P<0.001). The high proportion of papillary RCC in AA patients was maintained across disease stages. On univariable analyses, AA patients had better recurrence-free and cancer-specific survival. On multivariable analyses, AA race was not a significant predictor of oncological outcomes after adjusting for patient and disease characteristics. ConclusionIn this study, AA patients presented with more localized disease than non-AA patients, whereas rates of benign disease were comparable between the groups. Furthermore, AA patients had roughly 3 times higher rates of papillary RCC across disease stages. On univariable analyses, AA patients appeared to have more favorable oncological outcomes. However, this association is likely explained by tumor stage, grade, and histology as outcomes were similar across races when the analyses were adjusted for these and other characteristics.

Bilateral multifocal papillary type I renal cell carcinoma: Clinical characteristics and association with chronic renal insufficiency.

482 Background: Patients with bilateral multifocal (BMF) RCC are at risk for multiple surgeries, progressive loss of renal tissue and chronic renal insufficiency. Although BMF papillary type I RCC is commonly associated with Hereditary Papillary Renal Cell Carcinoma (HPRC), with mutation of the MET proto-oncogene, sporadic (non-familial) BMF Pap1 RCC is far more common. Here we describe the histologic and clinical phenotype as well as clinical management of a population of patients with BMF RCC that has papillary type I histology that is distinct from the HPRC population. Methods: From 2000 to 2013, patients who were evaluated at the National Cancer Institute and were diagnosed with BMF on cross sectional imaging were included. Patients who tested negative for MET proto-oncogene mutation, who have a pathologic diagnosis of papillary type I were included. Phenotypic manifestations and clinical management were analyzed. Results: 61 patients with an average age of 54.3 years were identified. A disproportionate number (22, 36%) of these patients were of African American descent. Fifty seven (93%) were male. Two patients were found to have had metastatic disease on presentation (3%); 17 patients underwent unilateral radical nephrectomy for renal mass (28%) even though the average largest tumor diameter was only 2.9 cm. 12 patients (19%) underwent partial nephrectomy. The average preoperative serum creatinine was 1.48 mg/dl and average eGFR 62.2 ml/min, there was no difference between in eGFR in African American patients and Caucasian patients (62.09 ml/min and 63 ml/min). This population had an average of 2 tumors per side, many patients also had numerous cysts on both kidneys. Conclusions: BMF papillary type I RCC represents a novel entity which disproportionally affects African Americans. These patients often present with renal insufficiency and are at significant risk for further renal deterioration. As a small percentage of these patients with BMF papillary type I will present with metastatic disease, active surveillance until the largest renal tumor reaches 3 cm is recommended.

Partial Nephrectomy for T1b Renal Cell Carcinoma: A Safe and

Partial Nephrectomy for T1b Renal Cell Carcinoma: A Safe and

Association of a high SCORED value and chronic kidney disease following radical nephrectomy for renal masses

5117 Background: Radical nephrectomy (RN) represents the definitive surgical intervention for patients with renal masses suspicious for malignancy and a normal contralateral kidney. However, patients with renal masses are at risk for having or developing chronic kidney disease (CKD) stage III (GFR<60 ml/min/1.73m2) which places them at a higher risk for cardiac morbidity and mortality. We examined if a validated predictive model (SCORED) could help stratify the risk of CKD in patients with renal masses. Methods: We identified 293 consecutive patients who underwent RN for a renal mass without evidence of metastatic disease and with a normal contralateral kidney. Using preoperative risk factors, we stratified patients into low (<4) and high (≥4) SCORED values. Glomerular filtration rates (GFR) were estimated by the MDRD equation. Results: In our cohort, RN was performed for renal masses with an average size of 6.9 cm (range 2–24). A higher SCORED value was associated with a higher risk of patients having CKD stage III prior to surgery (38% vs 18% with a lower SCORED value, p <0.004). Furthermore, among patients with a pre-operative GFR ≥ 60 ml/min/1.73m2, a higher SCORED value was associated with a significantly higher risk for developing CKD stage III postoperatively, at a median follow up of 39.0 months (52% and 65% risk of CKD vs 25% and 32% risk of CKD in patients with lower SCORED value at 12 months, and at 24 months respectively, p=0.010). In multivariate analyses including the size of the mass and pre-operative GFR, the SCORED value was associated with development of CKD. Comparative analyses with another cohort of 171 patients undergoing nephron sparing approaches (NSA) revealed that NSAs significantly protected patients from developing CKD stage III post-operatively. Conclusions: Despite a normal contralateral kidney, patients with high SCORED values are at a significant risk of having or developing CKD following RN for renal masses. Nephron-sparing approaches should be used whenever possible. These findings assume greater importance when considering overall survival outcomes of patients with kidney cancer, as CKD stage III is an independent risk factor for cardiovascular morbidity and mortality. No significant financial relationships to disclose.

Case report: Retroperitoneal fibrosis simulating local relapse of sarcomatoid renal cell carcinoma

Generally, retroperitoneal fibrosis is an idiopathic process that envelopes and displaces ureters, causing hydronefrosis and renal failure. CT scan is the best choice for diagnosis. Other aetiologies described are malignancies, drugs, aorta aneurisms and immunological or rheumatological diseases. A 53-year-old male with hypertension and diabetes was operated on radical nephrectomy for renal mass. Pathological examination showed sarcomatoid renal cell carcinoma, Fürhman 3 grade, pT2 N0. Within 6 months of surgery, control CT scan demonstrated a left retroperitoneal mass, without separation with pancreas queue and spleen hilium, suggesting local relapse. Resection of the mass with splenectomy and partial pancreatectomy en bloc was performed. Microscopic evaluation revealed a dense collagenic tissue with a prominent inflammatory infiltrate, and the immunohistochemical study was negative for cytokeratin AE1-AE3. There was no evidence of malignancy in the histological examination. All these findings aided to diagnose a retroperitoneal fibrosis. Sometimes retroperitoneal fibrosis can simulate or is associated to malignancies. Presentation of a retroperitoneal fibrosis simulating local relapse of sarcomatoid renal cell carcinoma has not been previously reported in the English literature.