Radical Nephrectomy In Patients Research Articles

MP77-01 TRENDS, OUTCOMES, AND COSTS OF HEMOSTATIC UTILIZATION FOR MAJOR UROLOGIC SURGERY

You have accessJournal of UrologyCME1 Apr 2023MP77-01 TRENDS, OUTCOMES, AND COSTS OF HEMOSTATIC UTILIZATION FOR MAJOR UROLOGIC SURGERY Camilo Arenas-Gallo, Patrick Lewicki, Megan Prunty, Aaron Brant, Stephen Rhodes, Spyridon P. Basourakos, Alec Zhu, Ilon Weinstein, Bashir Al Hussein Al Awamlh, and Jonathan E. Shoag Camilo Arenas-GalloCamilo Arenas-Gallo More articles by this author , Patrick LewickiPatrick Lewicki More articles by this author , Megan PruntyMegan Prunty More articles by this author , Aaron BrantAaron Brant More articles by this author , Stephen RhodesStephen Rhodes More articles by this author , Spyridon P. BasourakosSpyridon P. Basourakos More articles by this author , Alec ZhuAlec Zhu More articles by this author , Ilon WeinsteinIlon Weinstein More articles by this author , Bashir Al Hussein Al AwamlhBashir Al Hussein Al Awamlh More articles by this author , and Jonathan E. ShoagJonathan E. Shoag More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003351.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Hemostatic agents are used to prevent hemorragic complications in surgeries. The national trends in the use and the cost associated with these agents in major urologic procedures are largely unknown. METHODS: This retrospective US analysis used the Premier Healthcare database. Patterns of hemostatic agent use in major urologic surgeries were investigated and correlated with patient and hospital characteristics over the past two decades. Multivariable mixed-effects logistic regression was used to identify predictors of hemostatic agent use. RESULTS: The final patient cohort included 385,261 patient encounters for urologic surgery from 2000 to 2020. In 2020, hemostatic agents were used in 36.91% of prostatectomies, 41.69% of radical nephrectomies, 60.22% of partial nephrectomies and 40.77% of cystectomies. In the multivariable models, For patients undergoing prostatectomy odds for receiving hemostatic agent was 14% higher in Hispanic men (OR 1.07, CI 1.22- 1.24; p<0.001) and 7% lower in Black patients men (OR 0.93, CI 0.90- 0.97; p<0.001), 33% lower for open surgery compared to laparoscopic/robotic approach (OR 0.67, 95% CI 0.63- 0.71; p<0.001). For radical nephrectomy patients, odds of receiving hemostatic agent were 16% higher for open approach (OR 1.16, 95% CI 1.12- 1.21; p<0.001), 7% lower for Black race (OR 0.93, 95% CI 0.88- 0.99; p 0.014). For partial nephrectomy patients odds for receiving hemostatic were 18% higher for open approach (OR 1.18, 95% CI 1.10- 1.27; p<0.001). The specific cost for hemostatic use did not differ between lap/robotic and open approaches for any procedure. CONCLUSIONS: The use of hemostatic agents has increased markedly in the last decade. Patient characteristics, surgeon, and hospital factors are highly associated with the use of hemostatic agents. Specific costs of the hemostatic and the proportion of the total cost of hospitalization have increased. There is a great need to develop controlled clinical trials capable of demonstrating the true efficacy of hemostatic agents to determine their specific indications. Source of Funding: J.E.S is supported by the Frederick J. and Theresa Dow Fund of the New York Community Trust, the Vinney Scholars Award, and a Damon Runyon Cancer Research Foundation Physician-Scientist Training Award © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1101 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Camilo Arenas-Gallo More articles by this author Patrick Lewicki More articles by this author Megan Prunty More articles by this author Aaron Brant More articles by this author Stephen Rhodes More articles by this author Spyridon P. Basourakos More articles by this author Alec Zhu More articles by this author Ilon Weinstein More articles by this author Bashir Al Hussein Al Awamlh More articles by this author Jonathan E. Shoag More articles by this author Expand All Advertisement PDF downloadLoading ...

Renal functional and cardiovascular outcomes of partial nephrectomy versus radical nephrectomy for renal tumors: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to evaluate the postoperative renal and cardiovascular outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) for the treatment of renal carcinoma. A systematic literature search was performed on scientific databases including Scopus, Web of Science, MEDLINE, and EMBASE from their inception to September 2021. Studies comparing renal and cardiovascular outcomes between PN and RN in patients with renal cancer were included. The generic inverse variance method with random-effects models was used to determine the pooled hazard ratios and odds ratio for each outcome. Quality Assessment for observational studies was guided by the New-Castle Ottawa Scale. Overall, a total of 31 studies (n=51,866) reported renal outcomes, while 11 studies (n= 101,678) reported cardiovascular outcomes. When compared to PN, RN had a higher rate of new-onset postoperative EGFR <60 mL/min/1.73 m2 (HR 3.39; CI 2.45 - 4.70; I2=93%; P=<0.00001) and EGFR <45 mL/min/1.73 m2 (HR 4.70; CI 2.26 - 9.79; I2=98%; P=<0.0001). No difference was observed in new-onset advanced kidney disease and end-stage renal disease. A 19% reduction in cardiovascular events was observed in the PN group (HR 0.81; CI 0.70 - 0.93, P=0.002). No protective effect of PN was observed in new-onset or worsening hypertension (HR 0.85; CI 0.64 - 1.14, P=0.28) nor myocardial infarction (HR 0.86; CI 0.71 - 1.04, P=0.13). PN was associated with a decreased risk of postoperative early-stage CKD and cardiovascular events compared with RN. However, no benefit of PN over RN was observed in advanced CKD, new-onset or worsening hypertension, myocardial infarction, and cardiovascular mortality.

Impact of race and payor status on patterns of utilization of partial and radical nephrectomy in patients with localized renal cell carcinoma (RCC).

614 Background: Racial minorities experience intersecting forms of marginalization and suffer significant healthcare disparities. Prospective trials have shown similar outcomes with partial and radical nephrectomy among patients with localized RCC (Van Poppel et al Eur Urol 2011), and multiple studies suggest increasing use of the former technique (Breau et al Can J Urol 2020). We hypothesize that patients from minority groups, as well as those with non-private insurance, will have less access to this specialized procedure and therefore have a higher rate of radical nephrectomy. Methods: We utilized the California Office of Statewide Health Planning and Development (OSHPD) database that collects information from all inpatient admissions, emergency room visits and inpatient/outpatient procedures in the state. All patients undergoing nephrectomy (both partial and radical) were identified from Jan 1, 2012 to Dec 31, 2018 using CPT and ICD-9/10 codes to identify patients. Demographic data was collected with specific attention to race and payor status. Univariate and multivariate analyses were conducted to determine the association between demographic data and procedure type. Results: In total, 31,093 patients were identified; 57% were males, with a mean age of 58 years. Among these, 16,142 (51.9%), 8,645 (27.8%), 2,795 (9.0%), 2,032 (6.5%) and 1,479 (4.8%) were characterized as White, Hispanic, Asian, Black and other, respectively. Partial nephrectomy and radical nephrectomy were performed in 15,840 (50.9%) and 15,253 (49.1%) of patients. By race, partial nephrectomy was performed in 8,576 (53.1%), 4,107 (47.5%), 1,286 (46.0%), 1,124 (55.3%) and 747 (50.5%) of White, Hispanic, Asian, Black and other patients, respectively (p&lt;0.001). Use of partial nephrectomy also differed among patients based on payor status, with rates of 6,800 (56.4%), 5,036 (43.9%), 1,817 (38.3%) and 2,187 (77.7%) among patients with private, Medicare, indigent coverage (e.g., MediCal or Medicaid) and other insurance, respectively (p&lt;0.001). On multivariate analysis controlling for age, gender, comorbidities and frailty, race was independently associated with type of nephrectomy procedure. Conclusions: Our study confirms that race and payor status may have an influence on utilization of partial versus radical nephrectomy, with the highest rate of partial nephrectomies among Whites and patients with private insurance. Although there are multiple potential confounders (e.g., latency of diagnosis and resulting tumor size/complexity), it is possible that access to care may be an important driver of these disparities.

Renal function and survival following treatment for cT1N0 renal cell carcinoma in a veteran population.

642 Background: Radical nephrectomy (RN), nephron sparing surgery (NSS) and thermal ablation (TA) are associated with similar oncologic control for early-stage renal cell carcinoma (RCC). However, the potential protective role of nephron sparing treatments on renal function and its impact on non-cancer related mortality remains undetermined. Methods: We employed the national Veterans Affairs Corporate Data Warehouse (CDW) to identify patients diagnosed with cT1N0 RCC between 2000-2018. Laboratory and diagnosis data were used to calculate creatinine clearance and Charlson comorbidity score. Chronic kidney disease (CKD) was defined as creatinine clearance &lt; 60 milliliters per minute. Kaplan-Meier analysis and multivariable Cox regression analysis were used to evaluate overall survival. Results: Overall, there were 8279 Veterans with cT1N0M0 renal cell carcinoma diagnosed between 2000-2018 who received either RN (2946, 36%), NSS (4846, 59%) or TA (487, 6%). Median follow up time was 8 years (90% CI 2-15 years). Patients receiving RN were older than those receiving NSS (median age 64.0 vs 62.6 years, p&lt;0.01) but younger than those receiving TA (median age 67.9 years, p&lt;0.01). Patients receiving RN and TA had more comorbidities than patients receiving NSS (mean Charlson scores 0.76 vs. 1.00 vs. 0.66, p&lt;0.01. More patients among the RN group had CKD before RCC diagnosis than the NSS and TA groups (10% vs. 6% vs. 7%, p&lt;0.01). Among the subset of patients without CKD before treatment, 17% of RN, 8% of NSS, and 11% of TA developed CKD at least 1 year after treatment, (p &lt;0.01). Median OS was 11.5 years with RN, 14.2 years with NSS, and 10.3 years with TA. On multivariable analysis considering age, comorbidities, CKD, race, and year of treatment, compared to RN, NSS was associated with better OS (HR 0.75, p&lt;0.01) with a trend to improved survival with TA (HR 0.88, p=0.08). Conclusions: NSS or TA are associated with less post-operative renal dysfunction than RN in patients treated for cT1N0 RCC in the VAHCS. NSS is associated with improved OS compared to RN. Further studies are warranted to assess the impact of renal dysfunction in this population in relation to oncologic and survival outcomes.

Outcomes of partial nephrectomy for non-metastatic cT2 renal tumors: Results from a Canadian multi-institutional collaborative.

690 Background: The role of partial nephrectomy (PN) is not well defined for cT2 renal cell carcinoma (RCC) as compared to radical nephrectomy (RN). The aim of this study was to examine oncological outcomes of PN as compared to RN for non-metastatic cT2 RCC. Methods: The Canadian Kidney Cancer information system was used to define patients who underwent surgery for non-metastatic cT2 RCC from January 2011 to October 2022. Patients with clear-cell, papillary, and chromophobe RCC were included. Other histology, multiple tumours, and hereditary RCC syndrome patients were excluded. Each PN patient was individually matched to RN up to 1:4 depending on availability of patients based on tumor size (+/- 1cm), histology, grade (clear cell and papillary), and necrosis (clear cell). Matched patients were analyzed as clusters. Results: A total of 1523 patients were identified, and 50 PN patients met study criteria who were then matched to 185 RN patients. Both groups had similar age, gender, smoking status, BMI, Charlson comorbidity index score, symptoms at presentation, baseline eGFR, hemoglobin and pathological characteristics. PN patients had smaller tumors (7.6 cm [IQR 2] vs 8.4 [IQR 2.4], p=0.05), had higher likelihood of undergoing open surgery (72.9% vs 31.8%, p&lt;0.0001) and less likely received adrenalectomy (2% vs 24.3%, p=0.0004). Positive surgical margin rates were similar in both groups (8.2% in PN vs 3.4% in RN, p=0.2). Median follow up was not significantly different in either group (3.6 yrs [IQR 4.7] in PN vs 3.3 [4.7] yrs in RN, p=0.9). During the follow up period, PN patients had higher risk of local recurrence (HR 3.0, 95%CI 1.08-8.37), lower risk of distant metastasis (HR 0.36, 95%CI 0.15-0.88), better cancer specific survival (HR 0.56, 95%CI 0.18-1.78) and overall survival (HR 0.36, 95%CI 0.11-1.19) and as compared to RN. At 6 months and beyond after surgery, PN patients had less decline in eGFR than RN patients (-16.6 [SD 21.1] vs -24.4[SD 16.2], p=0.0002). Complications rates between PN and RN were (18% vs 9%, p=0.057). Conclusions: In this multi-institutional Canadian cohort of patients with non-metastatic cT2 RCC undergoing surgery, PN compared to RN was associated with slightly higher risk of peri-operative complications, better preservation of renal function, and higher risk of local recurrence. The lower risk of distant metastasis and death was likely from residual confounding unaccounted for in the individual patient match. [Table: see text]

Surgical Complications Requiring Reoperation in Open Versus Minimally Invasive Radical Nephrectomy: A Contemporary Analysis of the National Surgical Quality Improvement Program.

To explore reoperation rates for different radical nephrectomy (RN) approaches that are experiencing a shift from open radical nephrectomy (ORN) toward minimally invasive surgery (MIS), we aimed to compare reoperation rates along with their culprit etiologies between the different types of surgical approaches for RN. The national surgical quality improvement program dataset was used to select patients who underwent RN between the years 2012-2019. A 1:1 propensity score matched analysis was used. Reoperation rates and causes were then compared between open and MIS approach. The propensity matched cohort included 15,294 patients. Reoperation rates due to large bowel injury (0.01 vs. 0.14%), vascular injury (0.07 vs. 0.22%), and other abdominal (0.5 vs. 0.77%) were more common in ORN as compared to MIS (MIS vs. ORN, respectively, p < 0.034). Reoperation due to hernia (0.14 vs. 0.03%) was more common in MIS as compared to ORN (p = 0.027). No difference was seen for small bowel injury and incision/wound debridement. General reoperation (1.61 vs. 2.22%) and mortality (0.57 vs. 1.47%) were also more common in ORN as compared to MIS (p < 0.008). Reoperation due to large bowel injury, vascular injury, and other abdominal was more likely to occur in ORN. Whereas reoperation due to hernia was more likely to occur in MIS. Surgical approach was an independent risk factor for immediate and early reoperation rates in RN patients. These results could be used to counsel patients pre-operatively on possible surgical approaches and complications.

The incidence and risk factors of chronic kidney disease after radical nephrectomy in patients with renal cell carcinoma

BackgroundRadical nephrectomy (RN) is the standard treatment for localized renal cell carcinoma. The decrease in nephrons from RN could lead to postoperative chronic kidney disease (CKD). In this study, we aim to investigate the incidence and risk factors for CKD in patients who have received RN.MethodsA Total of 1233 patients underwent radical nephrectomy in Zhejiang Provincial People’s Hospital from January 2010 to December 2018. Those who had an abnormal renal function before surgery or were lost to follow-up were excluded. Five hundred patients were enrolled in the end. eGFR was calculated using the abbreviated MDRD equation. CKD was defined as eGFR less than 60 ml/min/1.73m2. The incidence of postoperative CKD was estimated using the Kaplan-Meier method. The independent risk factors for CKD occurrence were determined through logistic multivariate regression analysis.ResultsPatients were followed up for a median of 40 month (3–96 months), with CKD occurring in 189 cases. The 5-year cumulative incidence of CKD was 43.4%. There was a significant difference between these189 patients and the remaining patients without post nephrectomy CKD in terms of age, sex, weight, and preoperative eGFR(P<0.05). Multivariate regression analysis showed that age (OR = 1.038, 95%CI = 1.002–1.076), preoperative eGFR of the contralateral kidney (OR = 0.934, 95%CI = 0.884–0.988) and Immediate postoperative eGFR (OR = 0.892, 95%CI = 0.854–0.931) were independent risk factors for postoperative CKD.ConclusionsThe incidence of CKD after radical nephrectomy was not uncommon. Age, preoperative eGFR of the contralateral kidney and Immediate postoperative eGFR are independent risk factors for postoperative CKD.

Laparoscopic nephron sparing surgery and radical nephrectomy in cT1 renal tumors. Comparative analysis of complications and survival

Introduction and objectivesComparative analysis of postoperative complications and survival between laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) in cT1 renal cell carcinoma (RCC). Material and methodRetrospective study of patients with two kidneys and single renal tumor cT1 treated in our center between 2005 and 2018 by laparoscopic PN or RN. Results372 patients met the inclusion criteria for the study. RN was performed in 156 (41.9%) patients and PN in 216 (58.1%). Clavien Dindo III–V complications were observed in 10 (4,6%) PN and 6 (3,9%) RN patients (p = 0.75). The comorbidity Charlson index (CCI) was identified as an independent predictor variable of complications (p = 0.02) and surgical approach did not affect multivariate analysis. Estimated overall survival (OS) was 81.2% and 56.8% at 5 and 10 years in the RN group and 90.2% and 75.7% in the PN group, respectively (p = 0.0001). Obesity (HR 2.77, p = 0.01), CCI ≥ 3 (HR 3.69, p = 0.001) and glomerular filtration rate (GFR) <60 mL/min/1.73 m2 at discharge (HR 1.87, p = 0.03) were identified as predictors of overall mortality. Nephrectomy approach showed no influence on OS. Estimated recurrence-free survival (RFS) was 86.1% at 5 and 10 years in the RN group and 93.5% and 83.6% in the PN group, respectively (p = 0.22). ConclusionsLaparoscopic PN is not inferior to RN in terms of oncologic and surgical safety in cT1 RCC. Nephrectomy approach did not influence patient OS, however, obesity, CCI ≥ 3 and GFR <60 mL/min/1.73 m2 at discharge did behave as predictors.

Metastatic stage vs complications at radical nephrectomy with inferior vena cava thrombectomy

BackgroundTo investigate perioperative complication rates at radical nephrectomy (RN) according to inferior vena cava thrombectomy (IVC-T) status and stage (metastatic vs non-metastatic) within kidney cancer patients. Materials and methodsWe ascertained perioperative complication rates within the National Inpatient Sample database (2016–2019). First, log-link linear Generalized Estimating Equation function (GEE) regression models (adjusted for hospital clustering and weighted for discharge disposition) tested complication rates in IVC-T patients, according to metastatic stage. Subsequently, a subgroup analysis relied on RN patients with or without IVC-T. Here, multivariable logistic regression models tested complication rates in RN patients according to IVC-T status, after propensity score matching including metastatic stage. ResultsOf 26,299 RN patients, 461 (2%) patients underwent IVC-T. Of those, 252 (55%) were non-metastatic vs 209 (45%) were metastatic. Rates of acute kidney injury (AKI), transfusion, cardiac, thromboembolic and other medical complications in non-metastatic vs metastatic patients were 40 vs 40%, 25 vs 22%, 21 vs 23%, 19 vs 14% and 38 vs 40%, respectively (all p ≥ 0.2). Metastatic stage in IVC-T patients did not predict differences in complications in log-link linear GEE regression models (all p > 0.1). However, in logistic regression models with propensity score matching, relying on the overall cohort of RN patients, IVC-T status was associated with higher complication rates (all p < 0.001): AKI (Odds ratio [OR]:2.60; 95%-CI [95%-Confidence interval: 1.97–3.44), transfusions (OR:2.40; 95%-CI: 1.72–3.36), cardiac (OR:2.27; 95%-CI: 1.49–3.47), thromboembolic (OR:9.07; 95%-CI: 5.21–16.58) and other medical complications (OR:2.01; 95%-CI: 1.52–2.66). ConclusionsThe current analyses indicate that presence of concomitant IVC-T is associated with higher complication rate at RN. Conversely, metastatic stage has no effect on recorded complication rates.

MO189: The Clinical Relevance of Measured GFR in Patients with Solitary Kidney after Radical Nephrectomy: The Estimation is not Enough

Abstract BACKGROUND AND AIMS Chronic kidney disease (CKD) represents the major postoperative long-term complication in patients who undergo radical nephrectomy (RN) for the presence of a renal mass. The development of a mild to severe grade of CKD can dramatically change the lifespan of this category of patients who can experience not only an augmented rate of cardiovascular diseases but also cancer recurrence and oncological therapies based on nephrotoxic agents. Therefore, preventive strategies for reducing the risk of CKD are strictly required. Among them, one of the most important tools is represented by the correct assessment of renal function. In fact, especially in the oncological scenario, there are various causes of factitious elevation or reduction of serum creatinine due to the frequent modification of body composition, measurement interference with the assay and altered tubular secretion. Nevertheless, the use of estimated GFR based on serum creatinine levels remains nowadays the most common method to define renal function in RN patients, both in the oncological and in the urological universe. The aim of this study was to determine the extent of the error of eGFR compared to the mGFR in a consecutive prospective cohort of RN patients who remained with a solitary kidney. METHOD A total consecutive cohort of 115 RN patients enrolled in a single tertiary institution between 2018 and 2021 was collected in order to compare the most common eGFR formulas used by physicians (Cockroft-Gault, MDRD, CKD-EPI based on serum creatinine and/or serum cystatin and the new eGFR equation based on creatinine and cystatin without race adjustment) with the most widespread mGFR method (Iohexol Plasma Clearance). The mGFR technique together with the serum creatinine/cystatin measurement was performed after 12 months from the operation in order to consider a steady state for the chronic renal function. All clinical variables were reported for each pt. CKD classification was defined accorded to K-DIGO 2012 guidelines. The agreement between eGFR and mGFR was evaluated using bias (as median of difference), precision (as interquartile range of difference-IQR), accuracy (as P30) and total deviation index (TDI). The differences between cohorts were evaluated with Fisher's exact test and Chi-squared test for ordinal characteristics and Wilcoxon rank sum test for continuous variables. Data analysis was performed using programming language R and Python. RESULTS Clinical data were as follows: median age 66 (IQR 27.66), M/F ratio 4.48, median BMI 24.6 (IQR: 0.003, 24.6). 51.3% of patients had hypertension, 10.4% were diabetics. The median creatinine level in the overall population was 1.49 mg/dL (IQR: 0.8, 1.49), the median cystatin level was 1.33 mg/dL (IQR: 0.55, 1.33). Based on iohexol plasma clearance, 0.87% patients were classified in CKD in stage 1, 17.39% in stage 2, 39.13% in stage 3a, 25.22% in stage 3b, 16.52% in stage 4 and 0.87% in stage 5. Surprisingly, a non-negligible error was reported in each CKD class with a huge discrepancy between the eGFR formulas and the gold standard method (Figures 1 and 2), suggesting the pivotal role of mGFR in the clinical decision-making algorithm for RN patients. CONCLUSION In daily clinical practice, an appropriate nephrological tailored follow-up based on mGFR is mandatory for RN patients with a solitary kidney. In fact, a simple renal evaluation using eGFR can only increase the risk of clinical errors, sometimes underestimating and sometimes overestimating the real renal function with important medical consequences.

MP47-04 VALIDATION OF A 22-GENE EPITHELIAL-MESENCHYMAL TRANSITION (EMT) PROGNOSTIC SIGNATURE IN CLEAR CELL RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 May 2022MP47-04 VALIDATION OF A 22-GENE EPITHELIAL-MESENCHYMAL TRANSITION (EMT) PROGNOSTIC SIGNATURE IN CLEAR CELL RENAL CELL CARCINOMA Brittney Cotta, Srinivas Nallandhighal, Judith Stangl-Kremser, Trinh Pham, Jeffrey Tosoian, Kathryn Marchetti, Joel Berends, Mahir Maruf, Scott Tomlins, Todd Morgan, Ganesh Palapattu, Eman Abdulfatah, Aaron Udager, and Simpa Salami Brittney CottaBrittney Cotta More articles by this author , Srinivas NallandhighalSrinivas Nallandhighal More articles by this author , Judith Stangl-KremserJudith Stangl-Kremser More articles by this author , Trinh PhamTrinh Pham More articles by this author , Jeffrey TosoianJeffrey Tosoian More articles by this author , Kathryn MarchettiKathryn Marchetti More articles by this author , Joel BerendsJoel Berends More articles by this author , Mahir MarufMahir Maruf More articles by this author , Scott TomlinsScott Tomlins More articles by this author , Todd MorganTodd Morgan More articles by this author , Ganesh PalapattuGanesh Palapattu More articles by this author , Eman AbdulfatahEman Abdulfatah More articles by this author , Aaron UdagerAaron Udager More articles by this author , and Simpa SalamiSimpa Salami More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002618.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Current predictors of metastatic progression after radical nephrectomy for localized clear cell renal cell carcinoma (ccRCC) include clinicopathologic features such as tumor stage and grade. The addition of molecular tumor characteristics in a prognostic score may improve risk stratification and patient selection for enhanced follow up strategies or adjuvant therapies. METHODS: We retrospectively identified consecutive patients with ccRCC who underwent radical nephrectomy (RNx) for localized disease. Those who developed metastasis were identified. Whole-transcriptome mRNA sequencing of primary tumors was performed followed by gene set enrichment analysis (GSEA) for the most significant cancer hallmark pathways enriched in patients who did or did not develop metastasis. For each patient, the 22-gene epithelial mesenchymal transition (EMT) score was calculated (high vs. low), using cut-offs from a prior study using TCGA data. The prognostic impact of the EMT score was evaluated by performing multivariable cox-proportional hazard testing and Kaplan-Meier (KM) survival analysis. RESULTS: We analyzed 82 patients with median age 62 years and median tumor size 6 ±2.9 cm. The median time to metastasis after radical nephrectomy for patients who developed metastasis (n=12) was 18.2 months and median follow up 31.1 months for patients who did not develop metastasis (n=70). We observed a significant enrichment of EMT, myogenesis, inflammatory response and hypoxia hallmark pathways in patients with metastasis vs. those without metastasis. Kaplan-Meier survival analysis showed a significant decrease in metastasis-free survival in patients with a high EMT score (p=0.018). Multivariable analysis controlling for relevant clinicopathologic features such as age, sex, tumor size, tumor stage etc. revealed high EMT score to be significantly associated with development of metastasis [hazard ratio (HR) 7.2; 95% CI 1.15-44.8; p=0.035]. CONCLUSIONS: We validated a prognostic 22-gene epithelial mesenchymal transition (EMT) score in patients treated with radical nephrectomy for localized ccRCC. Pending further studies, the EMT score may improve risk stratification and select patients for adjuvant therapy. Source of Funding: UM-Peking University Joint Institute, NCI T32 © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e810 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brittney Cotta More articles by this author Srinivas Nallandhighal More articles by this author Judith Stangl-Kremser More articles by this author Trinh Pham More articles by this author Jeffrey Tosoian More articles by this author Kathryn Marchetti More articles by this author Joel Berends More articles by this author Mahir Maruf More articles by this author Scott Tomlins More articles by this author Todd Morgan More articles by this author Ganesh Palapattu More articles by this author Eman Abdulfatah More articles by this author Aaron Udager More articles by this author Simpa Salami More articles by this author Expand All Advertisement PDF DownloadLoading ...

LBA01-08 INTERIM ANALYSIS OF PADRES (PRIOR AXITINIB AS A DETERMINANT OF OUTCOME OF RENAL SURGERY NCT03438708) CLINICAL TRIAL

You have accessJournal of UrologyCME1 May 2022LBA01-08 INTERIM ANALYSIS OF PADRES (PRIOR AXITINIB AS A DETERMINANT OF OUTCOME OF RENAL SURGERY NCT03438708) CLINICAL TRIAL Kevin Hakimi, Steven Campbell, Mimi Nguyen, Nityam Rathi, Luke Wang, Brian Rini, Moshe Ornstein, Rana McKay, and Ithaar Derweesh Kevin HakimiKevin Hakimi More articles by this author , Steven CampbellSteven Campbell More articles by this author , Mimi NguyenMimi Nguyen More articles by this author , Nityam RathiNityam Rathi More articles by this author , Luke WangLuke Wang More articles by this author , Brian RiniBrian Rini More articles by this author , Moshe OrnsteinMoshe Ornstein More articles by this author , Rana McKayRana McKay More articles by this author , and Ithaar DerweeshIthaar Derweesh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002669.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In renal cell carcinoma (RCC), partial nephrectomy (PN) is imperatively indicated for individuals with solitary kidney, chronic kidney disease, or bilateral tumors. Neoadjuvant Tyrosine Kinase Inhibitor therapy can potentially cytoreduce renal tumors and may therefore permit PN in circumstances not otherwise feasible. We report interim analysis of the PADRES (Prior Axitinib as a Determinant of Outcome of Renal Surgery NCT03438708). METHODS: This was a single arm phase II clinical trial of neoadjuvant axitinib in patients with complex renal mass (RENAL nephrometry score 10-12 and cT1b-cT3M0) biopsy-proven clear cell RCC with strong indications for partial nephrectomy (PN), and in whom radical nephrectomy may result in dialysis dependence. Axitinib 5 mg was administered orally twice daily for 8 weeks prior to surgery. Primary outcome was reduction in longest tumor diameter based on imaging criteria; secondary outcomes included tumor response (RECIST), change in RENAL score, feasibility of PN, change in estimated glomerular filtration rate (∆eGFR), post-surgical complications, and survival outcomes. RESULTS: 27 patients consented for study of which 26 proceeded with protocol (median age 69 years; median follow-up 12 months). Prior to therapy, 19 (73.1%) patients had ≥ clinical T3a staged tumors. Post therapy, 17 (65.4%) patients had ≥T3a staged tumors, and 8/26 (31%) of patients were downstaged on imaging. Axitinib resulted in reductions in median tumor size (19%, 7.7 vs. 6.3 cm, p <0.001 and RENAL score (11 vs. 10, p <0.001); 21/26 (80.9%) had partial response, and 5/26 (19.2%) had stable disease by RECIST criteria. PN was performed in 20/26 (76.9%) with median ischemia time of 34 minutes and with 25/26 (96.8%) achieving negative margins. All radical nephrectomy patients had at ≥T3a tumors on final pathology. Five (19.2%) had Clavien III-IV post-surgical complications. At last follow up, median ∆eGFR was 4.5 mL/min/1.73m2, 1/26 (3.8%) died due to progression, and 2/26 (7.7%) had recurrence. CONCLUSIONS: In this interim analysis, neoadjuvant Axitnib resulted in significant reductions in tumor size and complexity, enabling partial nephrectomy in a cohort of highly complex renal masses, and with acceptable safety and functional preservation. Accrual is ongoing to reach a target of 50. Source of Funding: Pfizer © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1038 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Hakimi More articles by this author Steven Campbell More articles by this author Mimi Nguyen More articles by this author Nityam Rathi More articles by this author Luke Wang More articles by this author Brian Rini More articles by this author Moshe Ornstein More articles by this author Rana McKay More articles by this author Ithaar Derweesh More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP24-05 OUTCOMES OF PARTIAL NEPHRECTOMY FOR NON-METASTATIC cT2 RENAL TUMORS: RESULTS FROM A CANADIAN MULTI-INSTITUTIONAL COLLABORATIVE

You have accessJournal of UrologyCME1 May 2022MP24-05 OUTCOMES OF PARTIAL NEPHRECTOMY FOR NON-METASTATIC cT2 RENAL TUMORS: RESULTS FROM A CANADIAN MULTI-INSTITUTIONAL COLLABORATIVE Rahul Bansal, Ryan Sun, Frederic Pouliot, Ranjeeta Mallick, Simon Tanguay, Darrel Drachenberg, Richard Rendon, Alan So, Luke Lavallee, Antonio Finelli, Lucas Dean, Anil Kapoor, Bimal Bhindi, Lori Wood, Naveen Basappa, and Rodney Breau Rahul BansalRahul Bansal More articles by this author , Ryan SunRyan Sun More articles by this author , Frederic PouliotFrederic Pouliot More articles by this author , Ranjeeta MallickRanjeeta Mallick More articles by this author , Simon TanguaySimon Tanguay More articles by this author , Darrel DrachenbergDarrel Drachenberg More articles by this author , Richard RendonRichard Rendon More articles by this author , Alan SoAlan So More articles by this author , Luke LavalleeLuke Lavallee More articles by this author , Antonio FinelliAntonio Finelli More articles by this author , Lucas DeanLucas Dean More articles by this author , Anil KapoorAnil Kapoor More articles by this author , Bimal BhindiBimal Bhindi More articles by this author , Lori WoodLori Wood More articles by this author , Naveen BasappaNaveen Basappa More articles by this author , and Rodney BreauRodney Breau More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002563.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The role of PN is not well defined for cT2 renal cell carcinoma (RCC) as compared to radical nephrectomy (RN). The aim of this study was to examine oncological outcomes of PN as compared to RN for non-metastatic cT2 RCC. METHODS: The Canadian Kidney Cancer information system was used to define patients who underwent surgery for non-metastatic cT2 RCC from January 2011 to October 2021. Patients with clear-cell, papillary, and chromophobe RCC were included. Other histology, multiple tumours, and hereditary RCC syndrome patients were excluded. Each PN patient was individually matched to RN up to 1:4 depending on availability of patients based on tumor size (±1 cm), histology, grade (clear cell and papillary), and necrosis (clear cell). Matched patients were analyzed as clusters. RESULTS: A total of 1347 patients were identified, and 42 PN patients met study criteria who were then matched to 145 RN patients. Both groups had similar age, gender, smoking status, BMI, Charlson comorbidity index score, symptoms at presentation, baseline eGFR, hemoglobin and pathological characteristics. PN patients had smaller tumors (7.6 cm [IQR 7.2, 9.2] vs. (8.5 cm [IQR 7.6, 10.3], p=0.048), had higher likelihood of undergoing open surgery (75% vs. 30% p <0.0001), less likely received adrenalectomy (0 vs. 21%, p=0.0001) and had higher likelihood of positive surgical margin (PSM) (10% vs. 1%, p=0.025). Median follow up was not significantly different in either group (3.7yrs [IQR 1.1, 5.4] in PN vs. 2.8yrs [IQR 1.2, 5.6] in RN, p=0.79). During the follow up period, PN patients had higher risk of local recurrence (HR 4.38 95% CI 1.51-12.71) and lower risk of metastasis (HR 0.39; 95% CI 0.16-0.95), improved cancer specific survival (HR 0.65; 95% CI 0.22-1.87) and overall survival (HR 0.47; 0.17-1.27) as compared to RN (Fig. 1). CONCLUSIONS: In this multi-institutional Canadian cohort of patients with non-metastatic cT2 RCC undergoing surgery, PN was associated with higher likelihood of PSM and local recurrence as compared to RN and lower risk of distant metastasis, cancer related death or death from any cause. Despite individual patient matching, there is likely unadjusted selection bias resulting in superior cancer survival associated with PN. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e394 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rahul Bansal More articles by this author Ryan Sun More articles by this author Frederic Pouliot More articles by this author Ranjeeta Mallick More articles by this author Simon Tanguay More articles by this author Darrel Drachenberg More articles by this author Richard Rendon More articles by this author Alan So More articles by this author Luke Lavallee More articles by this author Antonio Finelli More articles by this author Lucas Dean More articles by this author Anil Kapoor More articles by this author Bimal Bhindi More articles by this author Lori Wood More articles by this author Naveen Basappa More articles by this author Rodney Breau More articles by this author Expand All Advertisement PDF DownloadLoading ...

Validation of a 22-gene epithelial-mesenchymal transition (EMT) prognostic signature in clear cell renal cell carcinoma.

377 Background: Current predictors of metastatic progression after radical nephrectomy for localized clear cell renal cell carcinoma (ccRCC) include clinicopathologic features such as tumor stage and grade. The addition of molecular tumor characteristics in a prognostic score may improve risk stratification and patient selection for enhanced follow up strategies or adjuvant therapies. Methods: We retrospectively identified consecutive patients with ccRCC who underwent radical nephrectomy (RNx) for localized disease. Those who developed metastasis were identified. Whole-transcriptome mRNA sequencing of primary tumors was performed followed by gene set enrichment analysis (GSEA) for the most significant cancer hallmark pathways enriched in patients who did or did not develop metastasis. For each patient, the 22-gene epithelial mesenchymal transition (EMT) score was calculated (high vs. low), using cut-offs from a prior study using TCGA data. The prognostic impact of the EMT score was evaluated by performing multivariable cox-proportional hazard testing and Kaplan-Meier (KM) survival analysis. Results: We analyzed 82 patients with median age 62 years and median tumor size 6 ±2.9 cm. The median time to metastasis after radical nephrectomy for patients who developed metastasis (n = 12) was 18.2 months and 31.1 months for patients who did not develop metastasis (n = 70). We observed a significant enrichment of EMT, myogenesis, inflammatory response and hypoxia hallmark pathways in patients with metastasis vs. those without metastasis. Multivariable analysis controlling for relevant clinicopathologic features such as age, sex, tumor size, tumor stage etc. revealed high EMT score to be significantly associated with development of metastasis [hazard ratio (HR) 7.2; 95% CI 1.15-44.8; ]. Conclusions: Here we validate a prognostic 22-gene epithelial mesenchymal transition (EMT) score in patients treated with radical nephrectomy for localized ccRCC. Pending further studies, the EMT score may improve risk stratification and select patients for adjuvant therapy.

Partial vs. radical nephrectomy in non-metastatic pT3a kidney cancer patients: a population-based study.

The aim of this study was to test for differences in cancer specific mortality (CSM) rates between radical nephrectomy (RN) and partial nephrectomy (PN) in pT3a nmRCC patients. Within the surveillance, epidemiology, and end results database (2005-2016), 13,177 pT3a patients treated with either PN or RN were identified. Before and after 1:2 ratio propensity score (PS)-match between PN and RN patients, cumulative incidence plot and competing risks regression (CRR) were used to test differences in CSM and other cause mortality (OCM) rates. Relative to PN (N.=1615, 22.5%), RN patients harbored higher tumor size (72 vs. 38 mm; >70 mm 51 vs.10%), of more aggressive histology, collecting duct (0.4 vs. 0.2%) and sarcomatoid (2.3 vs.0.8%), of higher grade (51.0 vs. 37.5%). After PS-matching and OCM adjustment, 5-year CSM was 3-fold higher after RN than PN (P<0.01). Similarly, after PS matching and CSM adjustment, also 5-year OCM rates were higher after RN (HR: 1.59, P=0.0003). PN does not appear to compromise the oncological outcomes in patients with pT3a or high-grade renal masses when compared with RN. Therefore, these concerns should not deter a surgeon from attempting PN when otherwise technically feasible.

Nefrectomía parcial y radical laparoscópica en tumores renales cT1. Análisis comparativo de complicaciones y supervivencia

Introduction and objectivesComparative analysis of postoperative complications and survival between laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) in cT1 renal cell carcinoma (RCC). Material and methodRetrospective study of patients with two kidneys and single renal tumor cT1 treated in our center between 2005 and 2018 by laparoscopic PN or RN. Results372 patients met the inclusion criteria for the study. RN was performed in 156 (41.9%) patients and PN in 216 (58.1%). Clavien Dindo III-V complications were observed in 10 (4,6%) PN and 6 (3,9%) RN patients (p = 0.75). The comorbidity Charlson index (CCI) was identified as an independent predictor variable of complications (p = 0.02) and surgical approach did not affect multivariate analysis. Estimated overall survival (OS) was 81.2% and 56.8% at 5 and 10 years in the RN group and 90.2% and 75.7% in the PN group, respectively (p = 0.0001). Obesity (HR 2.77, p = 0.01), CCI ≥ 3 (HR 3.69, p = 0.001) and glomerular filtration rate (GFR) < 60 mL/min/1.73m2 at discharge (HR 1.87, p = 0.03) were identified as predictors of overall mortality. Nephrectomy approach showed no influence on OS. Estimated recurrence-free survival (RFS) was 86.1% at 5 and 10 years in the RN group and 93.5% and 83.6% in the PN group, respectively (p = 0.22). ConclusionsLaparoscopic PN is not inferior to RN in terms of oncologic and surgical safety in cT1 RCC. Nephrectomy approach did not influence patient OS, however, obesity, CCI ≥ 3 and GFR<60 mL/min/1.73m2 at discharge did behave as predictors.

Comparison of oncologic outcomes between elective partial and radical nephrectomy in patients with renal cell carcinoma in CT1B stadium

Background/Aim. In renal cell carcinoma (RCC), the choice of surgical technique, radical (RN) or partial nephrectomy (PN), is still center-dependent because there are still no absolute recommendations for this approach. The aim of this study was to analyze the oncological aspects, time until recurrent disease appears, and cancer-specific survival in patients with RCC in T1bN0?0 stadium depending on the type of surgical procedure, PN or RN technique. Methods. In a clinical observational study, data of 154 patients operated at the Clinic for Urology, Military Medical Academy, Belgrade, Serbia with a mean follow-up period of no less than five years were analyzed. Patients were divided into two groups; a group of patients with RN and a group of patients with PN. The inclusion criteria were: renal tumors 4?7 cm, histopathological confirmation of RCC, absence of metastasis, and normal serum creatinine. Exclusion criteria included: the presence of other malignancies, solitary functional kidney or comorbidities that can compromise renal function, bilateral tumors, or unilateral multiple tumors. Results. The study analyzed data from 154 patients, 97 (63%) RNs, and 57 (37%) patients that underwent PN. Analyzing cancer-specific survival in four patients with RN, there was a disease advancement that led to a lethal outcome, and one PN patient died as a result of local relapse and distant metastasis. Conclusion. Based on our results, PN is a good and safe treatment option for patients with RCC in T1b stadium. PN offers a similar tumor control and better cancer specific survival.

Functional, oncological outcomes and safety of nephron-sparing surgery versus radical nephrectomy in patients with localised renal cell carcinoma with high anatomical complexity: a retrospective cohort study with propensity score matching method

BackgroundNephron-sparing surgery (NSS) is widely applied for small renal masses. However, the indication of NSS in patients with localised renal cell carcinoma (RCC) with high anatomical complexity is controversial. Thus,...

Comparison of prognosis between patients undergoing radical nephrectomy versus partial nephrectomy for renal cell carcinoma ≤7cm T3aN0/xM0: Survival benefit is biased toward partial nephrectomy.

BackgroundThere is limited and controversial evidence on the prognosis of partial nephrectomy (PN) versus radical nephrectomy (RN) in patients with T3aN0/xM0 renal cell carcinoma (RCC) upstaged from clinical T1 RCC. In this study, we aimed to assess the prognosis difference following PN versus RN in patients with ≤7 cm T3aN0/xM0 RCC.MethodsFrom the Surveillance, Epidemiology, and End Results database, a total of 3196 patients receiving treatment of PN/RN for ≤7 cm T3aN0/xM0 RCC with only extrarenal fat extension in 2010–2017 were identified. An inverse probability of treatment weighting (IPTW)‐adjusted cause‐specific Cox model with hazard ratio (HR) and 95% confidence interval (CI) was used for overall survival (OS) and cancer‐specific survival (CSS) analyses. Sensitivity analysis was based on the propensity score matching of PN and RN groups and from the dataset of 2010–2013.ResultsA total of 872 patients underwent PN, compared with 2324 undergoing RN. After IPTW adjustment, there was no significant difference in preoperative baseline characteristics between the PN and RN cohorts. Patients who underwent RN had worse OS (HRIPTW‐adjusted, 1.46; 95% CI, 1.16–1.84; p = 0.001) and comparable CSS (HRIPTW‐adjusted, 1.03; 95% CI, 0.64–1.66; p = 0.890) than those receiving PN in all cohorts and subgroups with T3a RCC of ≤4 cm and perinephric fat extension. Further, in patients with 4–7 cm T3a RCC with perinephric‐fat invasion and all sizes of T3a RCC with sinus/perisinus fat extension, PN led to comparable OS and CSS. Sensitivity analyses validated these results.ConclusionPN provides comparable CSS and OS or even better OS than RN for patients with RCC ≤7 cm T3aN0/xM0. Although our study has some limitations, our results indicated that PN might oncologically safe for clinical T1 RCC, even confirmed a pathologically T3a upstaging post‐PN.

Parenchymal Volume Replacement by Renal Cell Carcinoma Prior to Intervention: Predictive Factors and Functional Implications

ObjectiveTo analyze predictors, extent and functional implications associated with renal parenchymal volume replacement (PVR) by renal cell carcinoma (RCC) prior to intervention. This phenomenon is well-recognized yet not adequately studied, and, if severe, can influence management. Materials and MethodsA retrospective review was performed of partial nephrectomy (PN) and radical nephrectomy (RN) patients with available preoperative nuclear-renal-scan and imaging demonstrating solitary RCC with normal contralateral kidney. Normal renal parenchymal volume of each kidney was measured by free-hand scripting from preoperative axial images. Primary endpoint was percent PVR which was estimated assuming that the contralateral-kidney serves as a control: PVR = (volume contralateral kidney – volume ipsilateral kidney) normalized by volume contralateral kidney. Multivariable linear-regression analysis assessed factors associated with preoperative PVR. Further analysis evaluated the functional effect of PVR prior to surgery. Results146 PN and 136 RN patients with necessary studies were analyzed. For RN, the median PVR was 15% and a quarter of patients had PVR ≥27%. In contrast, PVR was negligible in PN patients for whom median preoperative parenchymal volumes were nearly identical in the ipsilateral/contralateral kidneys (179/180cc, respectively). PVR inversely correlated with preoperative renal function in the ipsilateral kidney (P <.01). Tumor-size (P <.01), stage (P = .03), and endophytic properties (P = .03) associated with PVR on multivariable-analysis. ConclusionOur data suggest that substantial replacement of normal parenchyma by RCC occurs in many patients selected for RN and can contribute to preexisting renal-insufficiency. PVR prior to intervention is mainly driven by tumor characteristics in RN patients, but is negligible in most PN patients.