Renal Function Outcomes Research Articles

The safety and efficacy of laparoscopic microwave ablation-assisted partial nephrectomy: a new avenue for the treatment of cystic renal tumors

Purpose Clinically, the management of cystic renal masses is tricky. The study aims to evaluate the safety and efficacy of laparoscopic microwave ablation-assisted partial nephrectomy (LMAPN) for cystic renal tumors. Methods and materials Between November 2017 and January 2022, LMAPN was performed on 43 patients (29 men and 14 women; age range: 22–80 years; median age 54 years) with Bosniak category III (n = 15) or IV (n = 28) cystic renal tumors (size range: 1.2–5.0 cm; mean size 2.8 cm). The median follow-up period was 26 months (range: 7–56 months). Baseline and perioperative data, pathological features, renal function, postoperative complications and oncologic outcomes were collected and evaluated. Results Forty-three cystic renal tumors were successfully managed by LMAPN. The mean operating time was 79 min (range: 40–130 min). The mean time of renal pedicle clamping was 19 min (range: 12–25 min). Mean intraoperative blood loss was 28.4 mL (range: 10–80 mL). The mean postoperative hospitalization duration was 4 days (range: 2–6 days). Negative surgical margins were diagnosed in all cases. During the follow-up, no patient appeared with distant metastasis, wound or peritoneal cavity implantation. No major but minor complications of Clavien–Dindo grade I were encountered after the operation. The 1-, 3- and 4-year overall survival rate was 100%, 96.6% and 88.5%, respectively. Conclusion This is the first study focusing on LMAPN for cystic renal tumors, demonstrating its favorable feasibility, safety and disease control. Long-term follow-up is necessary to draw conclusions on the preference and advantages of the new therapeutic approach.

Renal Functional Outcomes in Patients With Angiomyolipomas: Surveillance vs Embolization vs Nephrectomy

To investigate renal functional outcomes of surveillance, embolization, and surgery for angiomyolipomas (AML). Longitudinal data regarding patients with AML were analyzed retrospectively in this two-center study. Demographic, radiographic, and functional data were tabulated according to treatment type. Primary outcome was change in renal function from diagnosis to within 6 months post-diagnosis (interim) and to latest GFR assessment. 318 patients were diagnosed with AMLs; mean follow-up was 6.2 years. 184 patients (57.9%) were managed with surveillance, 30(9.4%) underwent embolization, and 103(32.4%) underwent surgery (91 partial nephrectomy;12 radical nephrectomy). Baseline characteristics, including tumor size, age, and race differed (p<0.05). Surveilled AMLs were smaller (p<0.001) than the intervention groups: 1.9 cm vs. 5.4 cm (embolization) and 4.9 cm (surgery). Greater interim decreases in GFR were observed following intervention with embolization (-14.0%) or surgery (-11.8%), when compared with surveillance (-4.1%); however, this was not statistically significant (p=0.19). Latest GFR was also reduced more (p=0.02) with embolization (-14.1%) and surgery (-14.7%) when compared to surveillance (-6.0%). At latest determination, CKD progression by at least one stage occurred in 37.8% overall, including 33.7% of surveilled patients, and was not statistically different across the three cohorts (p=0.074). Within the study limitations, surveillance appears to be appropriate for most AML patients; embolization and surgical intervention should be reserved for selected patients with large and/or symptomatic AML. Renal functional deterioration is common in patients with AML, whether managed with surveillance, embolization, or surgery. Long-term monitoring of renal function should be obligatory for all AML patients.

Renal function outcome after selective bladder-preserving tetramodality therapy consisting of maximal transurethral resection, induction chemoradiotherapy and consolidative partial cystectomy in comparison with radical cystectomy for patients with muscle-invasive bladder cancer: a two-centre retrospective study.

To compare renal function (RF) outcomes after bladder-preserving tetramodal therapy against muscle-invasive bladder cancer (MIBC) to those after radical cystectomy (RC). This study included 95 patients treated with tetramodal therapy consisting of transurethral bladder tumour resection, chemoradiotherapy and partial cystectomy (PC) and 300 patients treated with RC. The annual change in the estimated glomerular filtration rate (eGFR) was compared using the linear mixed model. Renal impairment was defined as a >25% decrease from the pretreatment eGFR, and renal impairment-free survival (RIFS) was calculated. The association between treatment type and renal impairment was assessed. The number of patients who received neoadjuvant chemotherapy was 8 (8.4%) in the tetramodal therapy group and 75 (25.0%) in the RC group. After the inverse probability of treatment weighting adjustments, the baseline characteristics were balanced between the treatment groups. The mean eGFR before treatment in tetramodal therapy and RC groups was 69.4 and 69.6 mL/min/1.73 m2 and declined with a slope of -0.7 and -1.5 mL/min/1.73 m2/year, respectively. The annual deterioration rate of post-treatment eGFR in the tetramodal therapy group was milder than in the RC group. The 5-year RIFS rate in the tetramodal therapy and the RC groups was 91.2 and 85.2%, respectively. Tetramodal therapy was an independent factor of better RIFS compared with RC. RF was better preserved after tetramodal therapy than after radical therapy; however, even after tetramodal therapy, the eGFR decreased, and a non-negligible proportion of patients developed renal impairment.

Comparison of robot-assisted partial nephrectomy with soft coagulation and double-layer technique for complex and non-complex tumors.

To compare the postoperative outcomes of robot-assisted partial nephrectomy when only the inner layer is sutured (single-layer technique with soft coagulation) with those when sutures are placed in the inner and outer layers (double-layer technique) in patients with and without complex renal tumors. This retrospective three-institution study included 371 patients with renal tumors who underwent robot-assisted partial nephrectomy with a double-layer technique or a single-layer technique with soft coagulation. Tumors that were cT1b, completely embedded, located in the renal portal, or had a RENAL score of ≥10 were considered complex. Relevant data were collected from hospital records. Propensity score matching was performed to minimize selection bias. Propensity score matching created 83 patient pairs with non-complex tumors and 32 with complex tumors. Regardless of tumor complexity, there was no significant difference in operation time, console time, warm ischemia time, positive surgical margin rate, or length of hospital stay between the double-layer and single-layer groups. Although Clavien-Dindo grade I-II urinomas not requiring intervention were significantly more common in the single-layer group regardless of tumor complexity, there was no significant between-group difference in the rate of decline in renal function or grade III-IV complications. Single-layer suturing with soft coagulation achieves renal function and perioperative outcomes comparable to those of double-layer suturing regardless of complexity.

Oncological and Renal Function Outcomes in Patients Who Underwent Simultaneous Radical Cystectomy and Nephroureterectomy for Synchronous or Metachronous Panurothelial Carcinoma

To assess clinical outcomes of patients who underwent simultaneous radical cystectomy (RC) and radical nephroureterectomy (RNU) for panurothelial carcinoma (PanUC). A retrospective analysis of 67 patients who underwent simultaneous RC and unilateral RNU for PanUC, from 1996 to 2017. Kaplan-Meier estimates for remnant urothelium recurrence-free survival, metastasis-free survival, overall survival (OS), and cancer-specific survival (CSS) were performed. Cox multivariate models were constructed. The median follow-up was 38 months, 29.8% of patients had a recurrence, 34.3% had metastasis, 67.2% of patients died from any cause, and 37.3% died from urothelial carcinoma. Overall survival and CSS rates at 5 years were 44% and 61%, respectively. In multivariate analysis, progression to muscle-invasive bladder cancer before surgery, presence of muscle-invasive stages at RC and/or RNU, and prostatic urethra involvement were predictors for worse metastasis-free survival and CSS. Forty-one patients (61.2%) had an estimated glomerular filtration rate (eGFR) <60 mL/min beforesurgery and the number rose to 56 (83.5%) after surgery; 29.8% patients needed renal function replacement therapy after surgery (16 haemodialysis and 4 renal transplant). Patients with PanUC who undergo simultaneous surgery have adverse oncological (only 4 out of every 10 remain alive at 5 years) and functional outcomes (1 out of 3 will need renal function replacement therapy after surgery). Up to a third of the patients had a recurrence (urethra or contralateral kidney) within 18 months, justifying close surveillance or considering prophylactic urethrectomy. These data should help in counsel on morbidity and life expectancy.

Blood creatinine and urea nitrogen at ICU admission and the risk of in-hospital death and 1-year mortality in patients with intracranial hemorrhage.

The relationship between renal function and clinical outcomes in patients with intracranial hemorrhage is controversial. We investigated the associations of blood creatinine and urea nitrogen levels with hospital death and 1-year mortality in patients with intracranial hemorrhage treated in the intensive care unit (ICU). A total of 2,682 patients with intracranial hemorrhage were included from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Clinical variables, including admission creatinine, urea nitrogen, type of intracranial hemorrhage, underlying diseases and other blood biochemistry parameters, were collected. Multivariable correction analysis was conducted of the relationships between blood creatinine and urea nitrogen levels on admission with hospital death and 1-year mortality in the included patients with intracranial hemorrhage. Smooth curve and subgroup analyses were also performed for these associations. A total of 2,682 patients had their blood creatinine and urea nitrogen levels measured within the first 24 h after ICU admission, with median values of 0.80 and 15.00 mg/dL, respectively. We observed steeply linear relationships between creatinine and urea nitrogen levels and the risk of in-hospital death and 1-year mortality, but the risk of in-hospital mortality and 1-year mortality increased little or only slowly above creatinine levels > 1.9 mg/dL or urea nitrogen > 29 mg/d (the inflection points). Consistently, conditional logistic regression analysis suggested that these inflection points had significant modification effects on the associations between blood creatinine levels, as well as blood urea nitrogen, and the risk of in-hospital death (interaction value < 0.001) and 1-year mortality (interaction value < 0.001). Our results supported the hypothesis that elevated blood creatinine and urea nitrogen levels on admission are associated with an increased risk of in-hospital death and 1-year mortality in patients with intracranial hemorrhage. Interestingly, these independent relationships existed only for lower levels of serum creatinine (<1.9 mg/dL) and uric acid (<29 mg/dL).

AUTHOR REPLY

We appreciate the insightful comments from Dr. Russo underlining the need for careful consideration regarding the optimal management strategy for newly diagnosed renal masses. Given the prevalence of comorbid conditions, such as hypertension and diabetes, among adults in the United States and the growing use of cross-sectional imaging, urologists increasingly encounter adults with renal malignancy and preexisting chronic kidney disease (CKD). Consideration of both operative and non-operative interventions based on the size and location of the renal mass, competing comorbidities, expected renal function outcomes, and life expectancy remains prudent.

Long-Term Outcomes of SABR to Primary Renal Cell Carcinoma: A Multicenter Analysis from IROCK (International Radiosurgery Oncology Consortium for Kidney)

<h3>Purpose/Objective(s)</h3> Patients with renal cell carcinoma (RCC) not suitable for surgery have few curative treatment options, particularly as thermal ablation has diminishing efficacy in RCC > 3 cm or adjacent to collecting system. Stereotactic ablative body radiotherapy (SABR) is a novel option limited by lack of long-term outcome data. We hypothesize that SABR represents an effective and safe, nephron-sparing alternative for RCC in the long-term. <h3>Materials/Methods</h3> Individual patient data from 12 institutions from IROCK were pooled. Patients with M1 disease and/or upper tract urothelial carcinoma were excluded. Minimum eligible follow-up was ≥ 2 years. Demographics, treatment, oncologic and renal function outcomes were assessed using descriptive statistics. Kaplan-Meier estimates and univariable and multivariable Cox proportional hazards regression were generated for oncologic outcomes. Local failure was investigator defined using RECIST 1.1. Patterns of failure were described using a cumulative incidence function with death as competing event. Toxicity was described using CTCAE v4.0. <h3>Results</h3> In 190 patients, the median follow-up was 5.0 years (range?). The mean ± SD tumor diameter was 4.2 ± 2.2 cm and 95 patients (50%) had ≥ T1b (≥ 4 cm) primaries. Median age was 74 years (interquartile range [IQR]: 66-82), 73.2% were male and 87.6% had good performance status (ECOG 0-1 or KPS ≥ 70%). In patients for whom operability details were reported, 75.0% were defined as inoperable by the referring urologist, mostly for cardiovascular comorbidities (46.9%). Baseline tumor complexity was moderate (median RENAL [1] score of 7 [IQR: 5-9]), and 56 patients (29.5%) had a solitary kidney. Mean ± SD BED₁₀ delivered was 88.3 ± 24.7 Gy. Mean ± SD baseline estimated glomerular filtration rate (eGFR) was 58.9 ± 22.6 mL/min (mild-to-moderate dysfunction) with 53 patients (28.0%) of the cohort having moderate-to-severe dysfunction (eGFR < 45 mL/min). At 3- and 5-years following SABR, mean ± SD eGFR decreased by -10.8 ± 16.6 mL/min and -13.5 ± 14.9 mL/min, respectively. Nine patients (4.7%) required dialysis. Seventy patients (36.8%) had a grade 1-2 toxicity, and one patient (0.5%) had a grade 4 toxicity (gastrointestinal). Cancer-specific survival (CSS) and progression-free survival (PFS) at 3 years were 95.5% and 72.1%, and at 5 years were 92.0% and 63.6%, respectively. Local, distant and any failure at 5 years were 5.5%, 10.8% and 13.0%. On multivariable analysis, increasing tumor size was associated with inferior CSS (HR per 1 cm increase: 1.41; 95% CI: 1.15-1.71; <i>p</i> < 0.001), PFS (HR: 1.10; 95% CI: 1.01-1.19; <i>p</i>=0.030), and any failure (HR: 1.20; 95% CI: 1.10-1.32; <i>p</i> < 0.001). <h3>Conclusion</h3> At 5-years post-therapy, SABR for primary RCC was associated with excellent local efficacy and good oncological outcomes, with only modest impact on renal function. [1] A. Kutikov & R.G. Uzzo "The RENAL nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth." J. Urol (2009)182(3):844

Safety and Efficacy of Stereotactic MRI-Guided Adaptive Radiation Therapy for Localized Kidney Cancer

<h3>Purpose/Objective(s)</h3> To assess the safety, feasibility as well as short term oncologic and renal functional outcomes of stereotactic MRI guided adaptive radiotherapy (SMART) for localized kidney cancer. <h3>Materials/Methods</h3> Single institution experience of patients undergoing MRI guided radiation therapy with daily plan adaptation for localized kidney cancer from 2020-2021. Patients were treated to a dose of 4000cGy over 5 fractions utilizing a 0.35T MR-Linac. Prior to each fraction, a pre-treatment MRI was obtained to allow for re-contouring of tumor and organs-at-risk. Patients were treated using an MR guided gated breath hold technique. Adverse events were classified according to the <i>Common Terminology Criteria for Adverse Events</i> (CTCAE) guideline version 5.0. <h3>Results</h3> Our cohort includes 12 patients with median age 75 years, median tumor diameter 4.75 cm, and median RENAL Nephrometry score 7. In terms of staging, 5 were cT1a, 5 were cT1b, 1 was cT2a, and 1 was cT3a. In total, 67.7% of patients had baseline Stage III CKD or worse renal function, and median Charlson Comorbidity index was 8. Histologic subtypes were 58.3% RCC and 25% papillary RCC. There was a total of 11 adverse events (AE) within 90 days: 10 were grade 1 for fatigue, nausea, vomiting, and diarrhea; there was one grade 2 AE for nausea (Table 1). No grade 3 or higher events were observed. The median baseline eGFR was 56.5 mL/min/1.73m², with median change in eGFR of -10 mL/min/1.73m² and the median change in tumor diameter was -0.5 cm at 7.5 months of follow-up, with no local or distant progression. No SMART-related hospital admissions occurred (Figure 1). <h3>Conclusion</h3> SMART is a treatment option for localized RCC that is associated with minimal toxicity, limited decline in renal function, and high rates of local tumor control. For patients who are not surgical candidates, SMART may be an effective therapy for localized kidney cancer.

The anti-inflammatory activity of resveratrol in acute kidney injury: a systematic review and meta‐analysis of animal studies

Context Accumulated experimental evidence suggests that resveratrol (RSV) may have an effect on acute kidney injury (AKI) by inhibiting inflammation. However, the credibility of the evidence for this practice is unclear. Objective This study investigated the effect of RSV on AKI and the underlying mechanism. Methods We searched PubMed, EMBASE, and Web of Science from 2005 to April 2022 for controlled animal trials assessing the effect of conventional resveratrol versus placebo on renal function outcome after AKI. This study was registered within the International Prospective Register of Systematic Reviews (PROSPERO) as number CRD42022329596. Results We retrieved 455 studies, 25 studies comprising data of 436 animals that met the inclusion criteria. Our meta-analysis suggested that RSV treatment was significantly associated with lower levels of serum creatinine (Scr) and blood urea nitrogen (BUN). The greatest effects were recorded in low-dose (<20 mg/kg/day) groups rather than in high-dose (> 20 mg/kg/day) groups. For time-response effects, subgroup analysis indicated that intervention duration of RSV can influence the treatment effect, and more beneficial effects were observed when studies had a drug administration time of <2 weeks. Discussion and conclusions This systematic review of animal AKI studies showed a consistently favourable effect of RSV as compared to placebo on renal function outcomes that increased with lower TNF-α, IL-6, and IL-1β. RSV has a more beneficial effect on SA-AKI animal models than the others. When the RSV intervention dose was low (< 20 mg/kg/day) and the intervention time was <2 weeks, more benefits could be observed.

SC146 - Renal functional outcomes and risk of chronic kidney disease after nephrectomy in living kidney donors

SC146 - Renal functional outcomes and risk of chronic kidney disease after nephrectomy in living kidney donors

The Outcome of Sutureless in Partial Nephrectomy: A Systematic Review and Meta-Analysis.

Purpose To compare the effect of sutureless versus standard suture (double-layer suture) during renorrhaphy in laparoscopic or robotic-assisted partial nephrectomy on perioperative and renal function outcomes. Methods PubMed, Embase, and other sources were searched for randomized controlled trials or retrospective studies comparing sutureless partial nephrectomy versus standard suture partial nephrectomy. A systematic review and meta-analysis were performed by two reviewers independently. Results Five retrospective studies were included with a total of 634 patients. The results showed that there was a significant difference in the decline of estimated glomerular filtration rate (I2 = 98.5%; WMD, -4.19 ml/min; 95% CI, -7.64 to -0.73; P < 0.001) and no significant difference in postoperative complications (I2 = 0; RR, 1.31; 95% CI, 0.61 to 2.81; P = 0.623). A significant advantage in terms of operating time (I2 = 53.9%; WMD, -29.08 min; 95% CI, -33.06 to -25.10; P = 0.069) and warm ischemia time (I2 = 38.5%; WMD, -6.17 min; 95% CI, -6.99 to -5.36; P = 0.165) favored sutureless, while there was no significant difference in blood loss (I2 = 58.1%; WMD, 3.10 ml; 95% CI, -39.18 to 45.38; P = 0.049). Conclusion Sutureless during renorrhaphy is feasible and safe compared with standard suture. Sutureless can shorten the operating time and warm ischemia time without increasing postoperative complications, and thus, it protects renal function.

Renal function in abdominal neuroblastoma patients undergoing proton radiotherapy.

The purpose of this study is to analyze renal function outcomes in abdominal neuroblastoma patients undergoing proton therapy (PT). From 2011 to 2019, two single-institution Institutional Review Board-approved protocols prospectively enrolled neuroblastoma patients for data collection. To assess renal function, serum creatinine (Cr), blood urea nitrogen (BUN), and creatinine clearance (CrCl) before proton therapy (pre-PT) were compared with the values at last follow-up. A total of 30 children with abdominal neuroblastoma with median age 3.5 years (range, 0.9-9.1) at time of PT were included in this study. All patients underwent chemotherapy and resection of primary tumor prior to PT. Two patients required radical nephrectomy. Median follow-up after PT was 35 months. Mean dose to ipsilateral and contralateral kidney was 13.9 and 5.4Gy, respectively. No patients developed hypertension or renal dysfunction during follow-up. There was no statistically significant change in serum BUN (p=.508), CrCl (p=.280), or eGFR (p=.246) between pre-PT and last follow-up. At a median follow-up of almost 3 years, renal toxicity was uncommon after PT. Longer follow-up and larger patient cohort data are needed to further assess impact of PT on renal function in this population.

Percutaneous nephrolithotomy and laparoscopic surgery efficacy and renal function outcomes for large and complex renal calculi

Abstract Background There is limited published evidence regarding the incidence of intraoperative and postoperative events and the effect of percutaneous nephrolithotomy (PCNL) in supine and prone positions and laparoscopic pyelolithotomy on kidney function in patients with large and complex calculi. Materials and methods We evaluated the surgical outcomes of 97 patients with large and complex kidney stones. The patients were divided into 3 groups: those who underwent PCNL in the prone position, PCNL in the supine position, and pyelolithotomy by laparoscopy and retroperitoneoscopy. General surgical outcomes, size of residual stones, stone-free rate, glomerular filtration rate (GFR), and split GFR obtained from Tc-99m renal dynamic scintigrams were analyzed. Results Percutaneous nephrolithotomy in the prone position was correlated with improved function of the affected kidney. In the supine PCNL group, none of the analyzed indicators demonstrated a significant difference. Dynamic nephroscintigrams revealed negative changes in terms of accumulation and secretion of the affected kidney. A slight decrease in creatinine clearance was noted. However, positive dynamics in split GFR and secretory index were seen in this group. The laparoscopic group showed positive results in all analyzed parameters. However, full assessment of the function of the affected kidney in this group was limited due to restricted use of laparoscopic pyelolithotomy for complex stones. Conclusions Percutaneous nephrolithotomy in the prone position resulted in the most favorable renal functional outcomes for patients with high-grade renal calculi, whereas a laparoscopic approach may be preferred for patients with stones of lower grades. The most significant factors that adversely affected renal function were intraoperative bleeding volume, kidney stone size and density, and body mass index.

The pathophysiology of bilateral and multifocal Wilms tumors: What we can learn from the study of predisposition syndromes.

Approximately 5% of patients with Wilms tumor present with synchronous bilateral disease. The development of synchronous bilateral Wilms tumor (BWT) is highly suggestive of a genetic or epigenetic predisposition. Patients with known germline predisposition to Wilms tumor (WT1 variants, Beckwith Wiedemann spectrum, TRIM28 variants) have a higher incidence of BWT. This Children's Oncology Group (COG)-International Society for Pediatric Oncology (SIOP-) HARMONICA initiative review for pediatric renal tumors details germline genetic and epigenetic predisposition to BWT development, with an emphasis on alterations in 11p15.5 (ICR1 gain of methylation, paternal uniparental disomy, and postzygotic somatic mosaicism), WT1, TRIM28, and REST. Molecular mechanisms that result in BWT are often also present in multifocal Wilms tumor (multiple separate tumors in one or both kidneys). We identify priority areas for international collaborative research to better understand how predisposing genetic or epigenetic factors associate with response to neoadjuvant chemotherapy, oncologic outcomes, and long-term renal function outcomes.

75: Stereotactic Body Radiotherapy for Renal Cell Carcinoma: Oncologic and Renal Function Outcomes

75: Stereotactic Body Radiotherapy for Renal Cell Carcinoma: Oncologic and Renal Function Outcomes

The efficacy of modified binding technique for renorrhaphy during robotic partial nephrectomy: surgical and functional outcomes from single-center experience

BackgroundTo compare the traditional single-layer and double-layer suture renorrhaphy with modified “Binding” suture renorrhaphy (whole rim of the wound was closed by the all-layer flow suture starting from the parenchyma cut edges to hilum, followed by the final defect closure) in robotic partial nephrectomy (RPN) for treating localized renal cell carcinoma in our large institutional experience.MethodsWe retrospectively reviewed clinical data of 406 consecutive patients who underwent RPN from May 2018 and December 2020 in our center. The demographic and oncologic outcome variables were compared between different renal reconstruction groups and the effect of these suture techniques on renal function outcomes was also evaluated.ResultsFor the single-layer group, median operative time and warm ischemic time were significantly less than that of the double-layer and “Binding” groups (p < 0.001), while the significantly lower eGFR drop (p = 0.014) was also detected within postoperative 3 months from baseline, but this difference lost its statistical significance from 3th month to the last follow-up. The changes in postoperative creatinine values were clinically insignificant among the three groups. In a sub-analysis over 258 patients with moderate/high nephrometry score, those patients who underwent “Binding” suture had an undifferentiated warm ischemic time, estimated blood loss, and length of hospitalization stay with a decreased risk of Grade III complications (postoperative hemorrhage requiring intervention) and improved renal function recovery during the whole follow-up.ConclusionSingle-layer suture renorrhaphy may be associated with better renal functional preservation and could prove to be reliable in patients with low-complexity tumor (RENAL score ≤ 6). Patients with moderate/high-complexity tumor (RENAL score ≥ 7) might represent a subgroup of patients having a functional benefit after “Binding” suture renorrhaphy even in the long-term period.Graphical abstract

Stereotactic Body Radiotherapy for Renal Cell Carcinoma: Oncological and Renal Function Outcomes

AimsTo evaluate oncological and renal function outcomes of stereotactic body radiotherapy (SBRT) for medically inoperable patients with localised renal cell carcinoma. Materials and methodsConsecutive patients treated with curative intent SBRT (30–45 Gy in five fractions or 42 Gy in three fractions) were included. Data on local control (Response Evaluation Criteria in Solid Tumors [RECIST] v1.1), distant metastasis, impact on estimated glomerular filtration rate (eGFR) and proportional ipsilateral and contralateral renal functions (measured through renal scans) were collected. Univariate and multivariable analyses were conducted to determine association of variables with oncological and renal function outcomes. ResultsSeventy-four patients were analysed. The median follow-up was 27.8 months (interquartile range 17.6–41.7). Fifty-seven per cent had tumours ≥ T1b. One-, 2- and 4-year cumulative incidence of local failure was 5.85, 7.77 and 7.77%, respectively. The cumulative incidence of distant metastasis at 2 years was 4.24%. On multivariable analysis, a lower planning target volume (PTV) mean dose (P = 0.019) and a larger PTV (P = 0.005) were significantly associated with the risk of developing local failure. A lower PTV maximum dose (P = 0.039) was significantly associated with the risk of developing distant metastasis. The median change in global eGFR (ml/min) from pre-SBRT levels was –7.0 (interquartile range –14.5 to –1.0) at 1 year and –11.5 (interquartile range –19.5 to –4.0) at 2 years. The proportion of ipsilateral (differential) renal function decreased over time from 47% of overall renal function pre-SBRT to 36% at 2 years, whereas the proportion of contralateral renal function correspondingly improved. On multivariable analysis, a higher volume of uninvolved renal cortex (P < 0.0001) was significantly associated with a smaller decrease in eGFR over time. ConclusionIn this large institutional cohort, oncological outcomes of renal cell carcinoma treated with SBRT were favourable and a longitudinal decline in renal function in the ipsilateral kidney and compensatory increase in the contralateral kidney were observed. Clinical and dosimetric factors were significantly associated with oncological and renal function outcomes.

Long-term clinical outcomes in older patients with acute venous thromboembolism who have renal impairment

IntroductionRenal impairment (RI) may induce an inflammatory/procoagulant state as well as platelet dysfunction. Little is known on the prevalence of RI and long-term prognosis of older patients with venous thromboembolism (VTE) who have concomitant RI. MethodsIn a prospective multicenter cohort, we analyzed 912 patients aged ≥65 years with acute VTE. Using the CKD-EPI formula, we defined three categories of baseline renal function: estimated glomerular filtration rate ≥60 ml/min/1.73m2 (no RI), 30–59 ml/min/1.73m2 (moderate RI), and <30 ml/min/1.73m2 (severe RI). The outcomes were VTE recurrence, major bleeding, and overall mortality. We examined the association between renal function and clinical outcomes using competing risk regression models, adjusting for relevant confounders and periods of anticoagulation. ResultsWe followed 912 patients over a median duration of 29.6 months. Overall, 313 (34%) patients had moderate and 51 (6%) severe RI. One hundred and seven patients (12%) had VTE recurrence, 125 (14%) had major bleeding, and 186 (20%) died during follow-up. After adjustment, severe RI was associated with a 2-fold increased risk of major bleeding (sub-hazard ratio [SHR] 2.1, 95% CI 1.1–4.0) compared to no RI, but not with VTE recurrence (SHR 0.6, 95% CI 0.2–1.8) or overall mortality (hazard ratio 1.0, 95% CI 0.6–1.9). Moderate RI was not significantly associated with adverse clinical outcomes. ConclusionsRI was common among older patients with acute VTE. Severe RI was associated with a 2-fold increased long-term risk of major bleeding, without a risk increase in terms of VTE recurrence and overall mortality. Older patients with moderate RI did not carry worse prognosis.

Management of neuropathic bladder secondary to spina bifida: Twenty years' experience with a conservative approach.

IntroductionTreatment of neuropathic bladder secondary to spina bifida is an ongoing challenge. Although different management strategies and protocols are available in the literature, reliance on expert opinion remains fundamental. A conservative approach can be utilized, but patients must be closely monitored throughout the management process. The objective of this study was to review the management and outcomes of neuropathic bladder in spina bifida by appraising long-term bladder and renal function in patients treated at a medical center utilizing a conservative management style.MethodsThis is a single-center retrospective review of urology care for all spina bifida patients 5–19 years of age with a neuropathic bladder who attended follow-ups between April 2000 and April 2020. Only patients with more than 5 years of follow-up were included. Renal functions, continence and results of invasive video urodynamics (IUD) and any surgical interventions were recorded.ResultsSeventy-one patients (mean age = 10.5 years) were identified after exclusions. Bladder compliance between first and last IUDs increased significantly (p = 0.0056). Anticholinergic treatment was started at the first outpatient appointment. Intravesical botulinum toxin injection was the second line treatment in ten patients. 94% of patients had an end fill pressure below 40 cm H2O in their last IUD. 82% were socially continent (dry or occasional damp patches) with or without catheterisations at the age of 11.5 years. One patient in the cohort had bladder augmentation.ConclusionThe optimal management of neuropathic bladder secondary to spina bifida remains controversial. Bladder and renal functional outcomes can be improved with close monitoring and less invasive management.