Surgery For Renal Cell Carcinoma Research Articles

Machine learning analysis for detecting late recurrence and loss to follow‐up after renal cell carcinoma surgery

AbstractObjectivesRenal cell carcinoma (RCC) is shown to have a tendency for late recurrence, occurring 5 or more years after curative surgery. Imaging diagnosis is required for follow‐up, and there is no definitive answer as to how long this should continue. Some patients discontinue follow‐up visits at their own discretion. How best to predict late recurrence and loss to follow‐up (LF) remains unclear.Patients and methodsThis study targeted patients diagnosed with non‐metastatic RCC who underwent either radical or partial nephrectomy at Chiba University Hospital between 1988 and 2021. Follow‐up for patients with RCC is typically lifelong. We used random survival forests (RSFs), a machine learning‐based survival analysis method, to predict late recurrence and LF. For verification of prediction accuracy, we applied the time‐dependent area under the receiver operating characteristic curve (t‐AUC). To analyse the risks of late recurrence and LF, SurvSHAP(t) and partial dependence plots were used.ResultsWe analysed 1051 cases in this study. Median follow‐up was 58.5 (range: 0–376) months. The predictive accuracy of recurrence using RSF was t‐AUC 0.806, 0.761, 0.674 and 0.566 at 60, 120, 180 and 240 months postoperatively, respectively. The recurrence risk impact showed a time‐dependent increase up to approximately 50 months postoperatively. Beyond 50 months, there were no distinct risk factors characteristic of late recurrence. The predictive accuracy of LF using RSF was t‐AUC 0.542, 0.699, 0.685, 0.628 and 0.674 at 60, 120, 180, 240 and 300 months postoperatively, respectively. The risk of LF increased with advancing age beyond 70 years.ConclusionIt is difficult to identify factors that predict late recurrence. For long‐term follow‐up observation, it is essential to pay particular attention to patients with RCC aged 70 years and above. Establishing frameworks to facilitate collaboration with local hospitals near patients' residences and providing care within the community is necessary.

Impact of Targeted Systemic Therapy and Radiotherapy on Patients Undergoing Spine Surgery for Metastatic Renal Cell Carcinoma.

In patients undergoing spine surgery for renal cell carcinoma (RCC), we sought to: (1) describe patterns of postoperative targeted systemic therapy and radiotherapy (RT), (2) compare perioperative outcomes among those treated with targeted systemic therapy to those without, and (3) evaluate the impact of targeted systemic therapy and/or RT on overall survival (OS) and local recurrence (LR). A single-institution, retrospective cohort study of patients undergoing spine surgery for metastatic RCC from 2010 to 2021 was undertaken. Treatment groups were RT alone, targeted systemic therapy alone, dual therapy consisting of RT and targeted systemic therapy, and neither therapy. Multivariable Cox regression controlled for age, race, sex, insurance, and preoperative targeted systemic therapy. Forty-nine patients underwent spine surgery for RCC. Postoperatively, 4 patients (8%) received RT alone, 19 (38.8%) targeted systemic therapy alone, 12 (24.5%) dual therapy, and 13 (28.6%) neither. All groups were similar in demographics, preoperative Karnofsky Performance Score (P = 0.372), tumor size (P = 0.413), readmissions (P = 0.884), complications (P = 0.272), Karnofsky Performance Score (P = 0.466), and Modified McCormick Scale (P = 0.980) at last follow-up. Higher 1-year survival was found in dual therapy (83.3%) compared with other therapies. OS was significantly longer in patients with dual therapy compared with other therapies (log-rank; P = 0.010). Multivariate Cox regression (HR = 0.08, 95% CI = 0.02-0.31, P < 0.001) showed longer OS in dual therapy compared with other therapies. Seven patients (14.3%) experienced LR, and a similar time to LR was found between groups (log-rank; P = 0.190). In patients undergoing metastatic spine surgery for RCC, postoperative dual therapy demonstrated significantly higher 1-year survival and OS compared with other therapies. Multidisciplinary management of metastatic RCC is necessary to ensure timely implementation of targeted systemic therapy and RT to improve outcomes.

Reoperation for ipsilateral local recurrence following prior nephron-sparing surgery: innovative surgical insights from a high-volume urological center with cross-sectional study.

The main aim of this study was to examine the perioperative results of reoperations and suggest novel surgical approaches. Based on a substantial number of robotic and laparoscopic nephron-sparing surgery (NSS), we aim to propose novel surgical strategies that offer practical recommendations to surgeons. Renal cell carcinoma patients with ipsilateral recurrent tumors, without evidence of metastasis, and who underwent primary NSS at our center between 2013 and 2023 were enrolled in this study, and all received the second time surgery. We conducted an analysis to evaluate perioperative outcomes and observed trends over a decade. Additionally, based on the findings from this study, we developed our surgical strategies. In the past decade, our center has successfully conducted a total of 2546 surgeries for renal cell carcinoma, out of which this study includes 15 patients who met the specified criteria. For reoperation, robotic-assisted surgery was applied in 5 cases (33.3%), laparoscopic surgery in 6 cases (40%), and open surgeries in 4 cases (26.7%). While 4 (26.7%) patients underwent NSS while radical nephrectomy was performed on 11 patients (73.3%). The median operative time was 215 minutes (IQR: 135-300), and the median estimated blood loss was 50ml (IQR: 50-100). The median length of postoperative hospitalization was 6 days (IQR: 5-9). Furthermore, there has been a yearly increase in the application of robotic-assisted NSS at our institution. Reoperation following the pNSS is a secure and effective surgical approach. We introduce novel surgical strategies for primary surgery and reoperation, which offer valuable insights to surgeons in current study.

MDSK‐Net: Multi‐scale dynamic segmentation kernel network for renal tumour endoscopic image segmentation

AbstractAutomatic segmentation of renal tumours during renal cell carcinoma surgery can help doctors accurately locate the tumour region, protect the tissues and organs around the kidneys, enhance surgical efficiency, and reduce the possibility of leakage and misdiagnosis. However, since general polyp endoscopic image segmentation models have many problems when facing the task of renal tumour segmentation, there needs to be more research on the segmentation of endoscopic images of renal tumours. This paper proposes a multi‐scale dynamic segmentation kernel network for endoscopic image segmentation of kidney tumours. First, a spatial receptive field module is proposed to augment the feature information and improve the performance of the whole network. Second, an enhanced cross‐attention module is offered to attenuate the effect of a high‐similarity segmentation background. Finally, a multi‐scale dynamic segmentation kernel module is introduced to gradually refine the segmentation results from small to large sizes to obtain more accurate tumour boundaries. Extensive experiments on the established kidney tumour endoscopic dataset and publicly available endoscopic datasets show that this method exhibits enhanced performance and generalization capabilities compared to existing techniques. On this renal tumour dataset, MDSK‐Net achieved excellent results of 94.1% and 90.1% on mDice and mIoU.

Pulmonary lesion after surgery for renal cancer: progression or new primary?

To investigate clinical and radiological differences between kidney metastases to the lung (RCCM +) and metachronous lung cancer (LC) detected during follow-up in patients surgically treated for Renal Cell Carcinoma (RCC). cM0 surgically-treated RCC who harbored a pulmonary mass during follow-up were retrospectively scrutinized. Univariate logistic regression assessed predictive features for differentiating between LC and RCCM + . Multivariable analyses (MVA) were fitted to predict factors that could influence time between detection and histological diagnosis of the pulmonary mass, and how this interval could impact on survivals. 87% had RCCM + and 13% had LC. LC were more likely to have smoking history (75% vs. 29%, p < 0.001) and less aggressive RCC features (cT1-2: 94% vs. 65%, p = 0.01; pT1-2: 88% vs. 41%, p = 0.02; G1-2: 88% vs. 37%, p < 0.001). The median interval between RCC surgery and lung mass detection was longer between LC (55months [32.8-107.2] vs. 20months [9.0-45.0], p = 0.01). RCCM + had a higher likelihood of multiple (3[1-4] vs. 1[1-1], p < 0.001) and bilateral (51% vs. 6%, p = 0.002) pulmonary nodules, whereas LC usually presented with a solitary pulmonary nodule, less than 20mm. Univariate analyses revealed that smoking history (OR:0.79; 95% CI 0.70-0.89; p < 0.001) and interval between RCC surgery and lung mass detection (OR:0.99; 95% CI 0.97-1.00; p = 0.002) predicted a higher risk of LC. Conversely, size (OR:1.02; 95% CI 1.01-1.04; p = 0.003), clinical stage (OR:1.14; 95% CI 1.06-1.23; p < 0.001), pathological stage (OR:1.14; 95% CI 1.07-1.22; p < 0.001), grade (OR:1.15; 95% CI 1.07-1.23; p < 0.001), presence of necrosis (OR:1.17; 95% CI 1.04-1.32; p = 0.01), and lymphovascular invasion (OR:1.18; 95% CI 1.01-1.37; p = 0.03) of primary RCC predicted a higher risk of RCCM + . Furthermore, number (OR:1.08; 95% CI 1.04-1.12; p < 0.001) and bilaterality (OR:1.23; 95% CI 1.09-1.38; p < 0.001) of pulmonary lesions predicted a higher risk of RCCM + . Survival analysis showed a median second PFS of 10.9years (95% CI 3.3-not reached) for LC and a 3.8years (95% CI 3.2-8.4) for RCCM + . The median OS time was 6.5years (95% CI 4.4-not reached) for LC and 6years (95% CI 4.3-11.6) for RCCM + . Smoking history, primary grade and stage of RCC, interval between RCC surgery and lung mass detection, and number of pulmonary lesions appear to be the most valuable predictors for differentiating new primary lung cancer from RCC progression.

#2171 The impact of preoperative hypertension and blood pressure control on kidney outcomes after surgery for localized kidney cancer: a prospective study

Abstract Background and Aims Kidney surgery represents the treatment of choice for localized renal cell carcinomas (RCC). Postoperative acute kidney injury (AKI) is reported in 40% of the patients undergoing partial nephrectomy [1]. A nephron-sparing approach is not always feasible for anatomical as well as oncological reasons and total nephrectomy is associated with an even higher risk of both acute and chronic impairment of renal function. Recently, interest has risen in the development of prediction models able to preoperatively identify patients at higher risk of AKI and chronic kidney disease (CKD) development after kidney surgery, but the role of hypertension in this field is yet underexplored. The aim of the present study was therefore to assess the impact of hypertension and blood pressure control on kidney outcomes after surgery for RCC. Method We prospectively enrolled 45 patients with an estimated glomerular-filtration-rate (eGFR) &amp;gt; 45 ml/min per 1.73 m2 who underwent kidney surgery for RCC at our institution between May 1, 2022, and September 30, 2023. Clinical characteristics of the study cohort are reported in Table 1. In-hospital AKI was defined as an increase of serum creatinine &amp;gt; 0.3 mg/dl from baseline and CKD development (defined as eGFR &amp;lt;60 ml/min/1.73 m2) was evaluated at 3 months. Ambulatory blood pressure monitoring (24h-ABPM) was assessed at baseline. Comparisons between groups were made by analysis of variance. Comparisons of proportions among groups were made using the χ2 test. Multivariate logistic regression analysis was used to describe the relationship between clinical variables and the presence of in-hospital AKI. Results Among the 45 patients enrolled, 42% (n = 19) developed postoperative AKI, of whom 32% (n = 6) had a complete kidney function recovery, whereas 68% (n = 13) developed CKD. Of the 39 patients with a basal ABPM evaluation, 87% (n = 34) had a diagnosis of hypertension. For 35% (n = 12) of these patients a first diagnosis of hypertension was made. AKI patients had higher median SBP (143 ± 9 vs 133 ± 12 mmHg, p = 0.008) and SBP variability (24 ± 4 vs 20 ± 5 mmHg, p = 0.01) compared with non-AKI patients. Preoperative 24h-SBP &amp;gt;130 mmHg was independently associated with in-hospital AKI (p = 0.05), regardless of age, gender, hypertension, diabetes and antihypertensive treatment. Considering the 3-month eGFR, we observed that compared with non-AKI patients, baseline 24h-SBP was higher, as a trend, in AKI patients who did not develop CKD or in those developing CKD on previous normal kidney function (de novo CKD), while no difference in 24h-SBP was observed between AKI and non-AKI patients in the subgroup of patients with preoperative CKD (CKD on CKD) (Fig. 1). Conclusion Preoperative hypertension, a potentially modifiable risk factor, is associated with an increased risk of AKI after kidney surgery. Moreover, an early identification of hypertension is of utmost importance taking into account that a strict blood pressure control, regardless of renal function at baseline, may be crucial to counteract the development or the progression of CKD.

A rare case of TFEB/6p21/VEGFA-amplified renal cell carcinoma diagnosed by whole-exome sequencing: clinicopathological and genetic feature report and literature review

BackgroundTFEB/6p21/VEGFA-amplified renal cell carcinoma (RCC) is rare and difficult to diagnose, with diverse histological patterns and immunohistochemical and poorly defined molecular genetic characteristics.Case presentationWe report a case of a 63-year-old male admitted in 2017 with complex histomorphology, three morphological features of clear cell, eosinophilic and papillary RCC and resembling areas of glomerular and tubular formation. The immunophenotype also showed a mixture of CD10 and P504s. RCC with a high suspicion of collision tumors was indicated according to the 2014 WHO classification system; no precise diagnosis was possible. The patient was diagnosed at a different hospital with poorly differentiated lung squamous cell carcinoma one year after RCC surgery. We exploited molecular technology advances to retrospectively investigate the patient’s molecular genetic alterations by whole-exome sequencing. The results revealed a 6p21 amplification in VEGFA and TFEB gene acquisition absent in other RCC subtypes. Clear cell, papillary, chromophobe, TFE3-translocation, eosinophilic solid and cystic RCC were excluded. Strong TFEB and Melan-A protein positivity prompted rediagnosis as TFEB/6p21/VEGFA-amplified RCC as per 2022 WHO classification. TMB-L (low tumor mutational load), CCND3 gene acquisition and MRE11A and ATM gene deletion mutations indicated sensitivity to PD-1/PD-L1 inhibitor combinations and the FDA-approved targeted agents Niraparib (Grade C), Olaparib (Grade C), Rucaparib (Grade C) and Talazoparib (Class C). GO (Gene Ontology) and KEGG enrichment analyses revealed major mutations and abnormal CNVs in genes involved in biological processes such as the TGF-β, Hippo, E-cadherin, lysosomal biogenesis and autophagy signaling pathways, biofilm synthesis cell adhesion substance metabolism regulation and others. We compared TFEB/6p21/VEGFA-amplified with TFEB-translocated RCC; significant differences in disease onset age, histological patterns, pathological stages, clinical prognoses, and genetic characteristics were revealed.ConclusionWe clarified the patient’s challenging diagnosis and discussed the clinicopathology, immunophenotype, differential diagnosis, and molecular genetic information regarding TFEB/6p21/VEGFA-amplified RCC via exome analysis and a literature review.

Relevance of Positive Surgical Margins in Localized Renal Cell Carcinoma After Surgical Resection: Predictive Factors and Survival Implications

IntroductionThe implications of positive surgical margins (PSM) after surgery for renal cell carcinoma (RCC) remain subject of discussion. This study aimed to identify risk factors for PSM, assess its effect on overall survival (OS), and determine predictors of OS. Patients and MethodsData from RCC surgeries at Mannheim University Medical Center between 2010 and 2023 was analyzed. Propensity score matching balanced PSM and control groups using age, surgical approach, tumor stage, histological subtype, and American Association of Anesthesiologists (ASA) score. Logistic and cox regression models predict PSM and OS, respectively. Kaplan–Meier analysis compared OS of PSM patients and controls. ResultsA total of 1066 RCC patients were included. Propensity score matching yielded 32 PSM patients and 96 controls. Multivariable logistic regression identified tumor stage ≥ T3a (odds ratio [OR] = 2.74, 95% confidence interval [CI] = 1.0-6.8, P = .04) and chromophobe, compared to clear cell, RCC (OR = 3.19, 95% CI = 1.0-8.7, P = .03) as independent predictors of PSM. Multivariable cox regression found age > 65 years (hazard ratio [HR] = 2.65, 95% CI = 1.7-4.2, P < .01) and tumor stage ≥ T3a (HR = 2.25, 95% CI = 1.4-3.7, P < .01) to predict shorter OS. Partial vs. radical nephrectomy was associated with improved OS (HR = 0.49, 95% CI = 0.3-0.9, P = .02). Kaplan–Meier analysis revealed no OS difference between PSM patients and controls (P = .49) over a 45-month median follow-up. ConclusionPSM is not a primary determinant of inferior survival, while age and tumor stage play a more prominent role. A well-calibrated follow-up protocol for PSM patients, combining PSM with coinciding factors such as tumor stage, grade, size, or PSM extent, is crucial for adequate surveillance while preventing excessive interventions.

Robot-assisted surgery of renal cell carcinoma in comorbid and frail patients

BACKGROUND: Renal cell carcinoma is predominantly observed in elderly patients. Many of them have multiple comorbidities, which can limit the feasibility of surgical treatment. The search for an optimal approach of radical treatment for comorbid and frail patients remains a current challenge. AIM: To evaluate the perioperative outcomes of robot-assisted partial nephrectomy and radical nephrectomy in comorbid and frail patients with renal cell carcinoma. MATERIALS AND METHODS: At the Almazov National Medical Research Centre we retrospectively studied the results of 118 comorbid and frail patients who underwent robot-assisted surgeries for localized renal cell carcinoma from 2012 to 2022. Mean age of men was 65.7 ± 11.4 years, and women was 61.3 ± 13.1 years. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Frailty was determined using a modified Frailty index (mFI-11). Robot-assisted partial nephrectomy and radical nephrectomy were perfomed by single experienced robotic surgeon. Perioperative functional outcomes were assessed. Renal function was evaluated based on glomerular filtration rate (GFR) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula before surgery and at 1.3, and 6 months after surgery. RESULTS: Among 118 patients, 71 (60.2%) underwent robot-assisted partial nephrectomy, while 47 (39.8%) underwent radical nephrectomy. Postoperative complications occurred in 15 (12.7%) of patients for robot-assisted surgeries. There were no positive surgical margins. Mortality in the early postoperative period amounted to 1.7% and was associated with the development of acute cardiovascular failure. CONCLUSIONS: Robot-assisted partial nephrectomy and radical nephrectomy for renal cell carcinoma in comorbid and “fragile” patients — the safest and optimal method of treatment, accompanied by minimal perioperative complications and mortality.

The Association of Body Composition Parameters Measured by Computed Tomography with Cancer Stage, Prognosis, and Survival in Patients with Renal Cell Carcinoma.

This study aims to investigate the association of preoperative body composition parameters, measured by computed tomography in patients undergoing surgery for renal cell carcinoma, with its stage and to survey the relationship with postoperative hospitalization duration and survival. Demographic data, pathology results, cancer stages, and hospitalization duration of 104 patients undergoing surgery at the urology clinic due to renal cell carcinoma between 2019 and 2023 were analyzed retrospectively. On computed tomography scans acquired during diagnosis, visceral adipose tissue, subcutaneous adipose tissue, total adipose tissue, and skeletal muscle area were measured. The ratios of body composition parameters were computed. When the correlation between survival time and body composition in deceased patients was analysed, a moderate but significant correlation was observed between skeletal muscle area value and total adipose tissue / skeletal muscle area ratio (r=0.630, p=0.001; r=0.598, p=0.002). A significant and strong correlation was observed between total adipose tissue value and survival (r=0.704, p<0.001). Subcutaneous adipose tissue / skeletal muscle area was found to be an independent risk factor associated with mortality, and a ratio of 0.98 or less increased the mortality risk approximately 16-fold. The relationship between body composition parameters measured by computed tomography, which can be easily evaluated pre-treatment, and mortality, postoperative recovery and length of hospital stay can be evaluated, giving clinicians an idea about the potential difficulties that patients may encounter during the treatment process. For this purpose, the subcutaneous adipose tissue / skeletal muscle area ratio is the most helpful parameter that can be used.</P>.

Utilization of Patient-Specific Characteristics and Competing Risks to Tailor the Duration of Surveillance Imaging After Surgery for Renal Cell Carcinoma

Purpose: The appropriate duration of follow-up after surgical resection of renal cell carcinoma (RCC) remains incompletely defined. To better inform on this time line, we investigate when an individual's risk of RCC recurrence becomes less significant than their risk of non-RCC death. Materials and Methods: We identified 1672 patients who underwent surgery for M0 RCC between 1999 and 2018. Patients were stratified by pathologic stage, histology, age, and Eastern Cooperative Oncology Group (ECOG) performance status. Cumulative incidence functions were estimated for RCC recurrence and non-RCC death using Fine and Gray models. Follow-up durations were estimated as the time point at which the cumulative incidence of non-RCC death exceeded that of RCC recurrence. Results: At a median follow-up of 2.1 years (IQR 0.6-5.1 years), a total of 272 recurrences (16.3%) and 234 non-RCC deaths (14.0%) occurred. The fitted model showed significant associations of stage with RCC recurrence and of age and ECOG with non-RCC death. For 50-year-old patients with pT1aN0-x clear cell and ECOG 0, the incidence of non-RCC death exceeded that of recurrence after 4.4 years. However, if such patients had an ECOG status of 1 or 2 to 4, the incidence of non-RCC death exceeded that of recurrence at 30 days, suggesting that routine oncologic surveillance may not be necessary. Alternatively, regardless of ECOG status, the incidence of non-RCC death failed to exceed that of recurrence for &gt;13.9 years in all patients age 50 with &gt; pT3aN0-x clear cell thereby suggesting longer surveillance than currently recommended. Conclusion: Modeling competing risks of RCC recurrence and non-RCC death provide patient-specific estimates when follow-up may be reasonably discontinued.

Effects of neoadjuvant VEGF‑TKI treatment on surgery for renal cell carcinoma: A systematic review and meta‑analysis.

To evaluate the effects of neoadjuvant vascular endothelial growth factor-tyrosine kinase inhibitor (VEGF-TKI) treatment on surgery in patients with renal cell carcinoma (RCC), sources from Embase, PubMed and the Cochrane Library databases collected from inception to December, 2022 were used for analysis in the present study, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data regarding surgical outcomes were collected. The pooled effect sizes were calculated in terms of the risk ratio (RR)/standard mean difference (SMD) with 95% confidence intervals (CIs) using the random-effects model. Subgroup and sensitivity analyses were used to explore the source of heterogeneity within the data. In total, 9 identified articles involving 829 patients (336 in the neoadjuvant + surgery group; 493 in the surgery group) were included in the present study, according to the criteria. The results demonstrated that there were no significant differences in blood loss (SMD=-0.11; 95% CI, -0.63-0.41; P=0.68), postoperative length of hospital stay or total length of hospital stay (SMD=0.23; 95% CI, -0.55-1.01; P=0.57) or complications (RR=1.16; 95% CI, 0.80-1.67; P=0.44) between the two groups. However, neoadjuvant therapy reduced the operation time (SMD=-0.67; 95% CI, -1.25- -0.09; P=0.02) and resulted in a greater proportion of patients choosing partial nephrectomy (RR=1.84; 95% CI, 1.47-2.31; P<0.00001). In the subgroup analysis, the blood loss was significantly lower in patients with RCC with inferior vena cava tumor thrombus in the neoadjuvant group (SMD=-1.10; 95% CI, -1.82- -0.38; P=0.003). In conclusion, the results of the present study indicated that neoadjuvant VEGF-TKI treatment in patients with RCC shortened operation time, decreased blood loss and did not cause an increase in perioperative complications. In addition, this treatment modality may encourage patients to opt for partial nephrectomy to preserve renal function.

Safety and efficacy of surgery in renal cell carcinoma with supradiaphragmatic tumor thrombus involving cardiac procedures.

484 Background: Invasion of the IVC is a unique feature of RCC. Tumor extension into the supradiaphragmatic IVC carries high morbidity and mortality attributable to surgical complexity. It is unclear whether safety and efficacy have been shown to warrant cytoreductive surgery for metastatic RCC with concomitant thrombus. We present outcomes of cytoreductive and non-cytoreductive radical nephrectomy (RN) with supradiaphragmatic tumor thrombectomy (TT) involving cardiac surgery. Methods: We reviewed our nephrectomy database for patients with RCC and supradiaphragmatic tumor thrombus. RN with TT was performed by a single team from urology, surgical oncology and cardiothoracic surgery. Rank Sum for numerical and chi-square for categorical variables were used to test for differences between cytoreductive and non-cytoreductive RN. Kaplan Meier curves estimated cancer-specific survival (CSS) and overall survival (OS). Results: From 2006-2023, 43 patients underwent RN with supradiaphragmatic TT. The tableindicates notable clinical and surgical features. No patient participated in a related clinical trial perioperatively. No case required circulatory arrest. One patient required temporary dialysis and later passed from multi-organ failure. 5-year CSS was 12% vs. 78% (p=0.007) and OS was 11% vs. 53% (p=0.044) for cytoreductive and non-cytoreductive surgery respectively. Conclusions: RN with supradiaphragmatic TT is safe with durable treatment response in patients with non-mRCC. Although safety of cytoreductive RN is comparable, further investigation into the role of neoadjuvant therapy is recommended. [Table: see text]

Amputation neuroma with a difficult differential diagnosis from perihilar cholangiocarcinoma:a case report

Biliary amputation neuroma is a rare benign tumor that develops due to the peribiliary dissection of nerve fibers during cholecystectomy, a common bile duct surgery, or lymph node dissection performed in gastric cancer surgery. We report a case of amputation neuroma that presented a challenging differential diagnosis from perihilar cholangiocarcinoma. A 64-year-old man, who had undergone open cholecystectomy 30 years ago, was incidentally found to have a bile duct tumor during computed tomography (CT) following surgery for renal cell carcinoma. He had no specific symptoms, and blood test results showed only a slight elevation in alkaline phosphatase levels. Contrast-enhanced CT revealed a 10-mm solid tumor with contrast effect in the common bile duct. On cholangiography, the tumor appeared as a protruding lesion with a smooth surface unilaterally. Given the atypical findings suggestive of cholangiocarcinoma, three bile duct biopsies were performed. Pathological examination did not rule out adenocarcinoma. The patient opted for surgery;however, an intraoperative rapid histological examination confirmed a benign disease, thereby avoiding extensive surgery. Consequently, a minimally invasive bile duct resection was performed. Postoperative histopathological examination revealed the tumor to be an amputation neuroma. Biliary amputation neuromas are characterized as unilateral protruding lesions with contrast effect or benign strictures. If such findings are observed in a patient with a history of surgery around the bile duct, the possibility of an amputation neuroma should be considered. However, completely ruling out malignancy preoperatively, even when suspecting amputation neuroma, can be challenging;therefore, considering surgery to achieve a definitive diagnosis is reasonable. During surgery, a rapid intraoperative histological examination is useful to avoid extensive procedures. In conclusion, diagnosing an amputation neuroma before surgery can be difficult, as it can mimic malignant tumors such as bile duct cancers. In this case, although a preoperative diagnosis of amputation neuroma was not feasible, performing a rapid intraoperative pathological examination helped avoid extensive surgery.

Initial experience in robot-associated radical nephrectomy with inferior vena cava tumor thrombectomy.

Renal cell carcinoma (RCC) is often locally invasive and may extend from the renal vein into the inferior vena cava (IVC) as a venous tumor thrombus (VTT). Radical nephrectomy with IVC tumor thrombectomy (IVC-TT) via an open approach has been shown to carry high morbidity and mortality. Recently, robot-associated radical nephrectomy (RARN) has been developed with the aim of improving the performance and outcomes of surgery for RCC with IVC-VTT. We here present four patients who had right RCC with IVC-VTT and underwent RARN with IVC-TT in Nagasaki University Hospital. All four patients had level II IVC-TT and underwent RARN with IVC-TT using a da Vinci Xi surgical system. The procedure comprised performing the Kocher maneuver, exposing the right renal artery in the aortocaval region dorsal to the left renal vein, exposing, mobilizing, and clipping the IVC, clamping and incising the IVC, and removing the kidney with the VTT en bloc. The mean tumor size was 83.1 (range, 50.1-115.2) mm and the mean length of the VTT within the IVC 41.6 (range, 25.3-44.3) mm. The mean console time was 290 (range, 287-367) minutes and the mean blood loss was 200 (range, 175-260) mL and no patient required blood transfusion. Our initial experience of the procedure of RARN with IVC-TT for level II IVC-VTT is that it is safe and has acceptable perioperative outcomes and complications.

P169 - Impact of intraoperative blood transfusions after surgery for renal cell carcinoma

P169 - Impact of intraoperative blood transfusions after surgery for renal cell carcinoma

Preoperative Renal Parenchyma Volume as a Predictor of Kidney Function Following Nephrectomy of Complex Renal Masses

BackgroundThe von Hippel-Lindau disease (VHL) is a hereditary cancer syndrome with multifocal, bilateral cysts and solid tumors of the kidney. Surgical management may include multiple extirpative surgeries, which ultimately results in parenchymal volume loss and subsequent renal function decline. Recent studies have utilized parenchyma volume as an estimate of renal function prior to surgery for renal cell carcinoma; however, it is not yet validated for surgically altered kidneys with multifocal masses and complex cysts such as are present in VHL. ObjectiveWe sought to validate a magnetic resonance imaging (MRI)-based volumetric analysis with mercaptoacetyltriglycine (MAG-3) renogram and postoperative renal function. Design, setting, and participantsWe identified patients undergoing renal surgery at the National Cancer Institute from 2015 to 2020 with preoperative MRI. Renal tumors, cysts, and parenchyma of the operated kidney were segmented manually using ITK-SNAP software. Outcome measurements and statistical analysisSerum creatinine and urinalysis were assessed preoperatively, and at 3- and 12-mo follow-up time points. Estimated glomerular filtration rate (eGFR) was calculated using serum creatinine-based CKD-EPI 2021 equation. A statistical analysis was conducted on R Studio version 4.1.1. Results and limitationsPreoperative MRI scans of 113 VHL patients (56% male, median age 48 yr) were evaluated between 2015 and 2021. Twelve (10.6%) patients had a solitary kidney at the time of surgery; 59 (52%) patients had at least one previous partial nephrectomy on the renal unit. Patients had a median of three (interquartile range [IQR]: 2–5) tumors and five (IQR: 0–13) cysts per kidney on imaging. The median preoperative GFR was 70 ml/min/1.73 m2 (IQR: 58–89). Preoperative split renal function derived from MAG-3 studies and MRI split renal volume were significantly correlated (r = 0.848, p < 0.001). On the multivariable analysis, total preoperative parenchymal volume, solitary kidney, and preoperative eGFR were significant independent predictors of 12-mo eGFR. When only considering patients with two kidneys undergoing partial nephrectomy, preoperative parenchymal volume and eGFR remained significant predictors of 12-mo eGFR. ConclusionsA parenchyma volume analysis on preoperative MRI correlates well with renogram split function and can predict long-term renal function with added benefit of anatomic detail and ease of application. Patient summaryPrior to kidney surgery, it is important to understand the contribution of each kidney to overall kidney function. Nuclear medicine scans are currently used to measure split kidney function. We demonstrated that kidney volumes on preoperative magnetic resonance imaging can also be used to estimate split kidney function before surgery, while also providing essential details of tumor and kidney anatomy.

Perioperative and oncologic outcomes of minimally-invasive surgery for renal cell carcinoma with venous tumor thrombus: a systematic review and meta-analysis of comparative trials.

The present study aimed to conduct a pooled analysis to compare the perioperative and oncologic outcomes of minimally-invasive radical nephrectomy with tumor thrombus (MI-RNTT) with open radical nephrectomy with tumor thrombus (O-RNTT). This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Four electronic databases (PubMed, Embase, Web of Science, and Cochrane Library database) were systematically searched to identify relevant studies published in English up to December 2022. The primary outcomes were perioperative results, complications, and oncologic outcomes. Review Manager 5.4 was used for this analysis. In total, eight retrospective trials with a total of 563 patients were included. Compared to O-RNTT, MI-RNTT had shorter hospitalization time (weighted mean difference [WMD] -3.58d, 95% confidence interval [CI] -4.56, -2.59; P<0.00001), lower volumes of blood loss (WMD -663.32mL, 95% CI -822.22, -504.42; P<0.00001), fewer transfusion rates (OR 0.18, 95% CI 0.09, 0.35; P<0.00001), fewer overall complications (OR 0.33, 95% CI 0.22, 0.49; P<0.00001), and fewer major complications s (OR 0.49, 95% CI 0.24, 1.00; P=0.05). However, operative time, intraoperative complications, mortality rate (intraoperative, within 30d, and total mortality), overall survival, recurrence-free survival, and cancer-specific survival did not significantly differ between the two groups. MI-RNTT possesses more benefits than O-RNTT in terms of length of hospital stay, blood loss, and complications and provides comparable mortality rates and oncologic outcomes. However, more comprehensive and rigorous research is warranted to further validate the outcomes, which should include a larger sample size and comprehensive data from high-volume medical centers.

Predictors for complication in renal cancer surgery: a national register study.

Nationwide register data provide unique opportunities for real-world assessment of complications from different surgical methods. This study aimed to assess incidence of, and predictors for, post-operative complications and to evaluate 90-day mortality following different surgical procedures and thermal ablation for renal cell carcinoma (RCC). All patients undergoing surgical treatment and thermal ablation for RCC in Sweden during 2015-2019 were identified from the National Swedish Kidney Cancer Register. Frequencies and types of post-operative complications were analysed. Logistic regression models were used to identify predictors for 90-day major (Clavien-Dindo grades III-V) complications, including death. The overall complication rate was 24% (1295/5505), of which 495 (8.7%) were major complications. Most complications occurred following open surgery, of which bleeding and infection were the most common. Twice as many complications were observed in patients undergoing open surgery compared to minimally invasive surgery (20% vs. 10%, P < 0.001). Statistically significant predictors for major complications irrespective of surgical category and technique were American society of anesthiologists (ASA) score, tumour diameter and serum creatinine. Separating radical and partial nephrectomy, surgical technique remained a significant risk factor for major complications. Most complications occurred within the first 20 days. The overall 90-day readmission rate was 6.2%, and 30- and 90-day mortality rates were 0.47% and 1.5%, respectively. In conclusion, bleeding and infection were the most common major complications after RCC surgery. Twice as many patients undergoing open surgery suffer a major post-operative complication as compared to patients subjected to minimally invasive surgery. General predictors for major complications were ASA score, tumour size, kidney function and surgical technique.

Low Skeletal Muscle as a Risk Factor for Worse Survival in Nonmetastatic Renal Cell Carcinoma with Venous Tumor Thrombus.

Renal cell carcinoma (RCC) with tumor thrombosis often requires nephrectomy and tumor thrombectomy. As an extensive and potentially morbid operation, patient preoperative functional reserve and body composition is an important consideration. Sarcopenia is a risk factor for increased postoperative complications, systemic therapy toxicity, and death solid organ tumors, including RCC. The influence of sarcopenia in RCC patients with tumor thrombus is not well defined. This study evaluates the prognostic ability of sarcopenia regarding surgical outcomes and complications in patients undergoing surgery for RCC with tumor thrombus. We retrospectively analyzed patients with nonmetastatic RCC and tumor thrombus undergoing radical nephrectomy and tumor thrombectomy. Skeletal muscle index (SMI; cm2/m2) was measured on preoperative CT/MRI. Sarcopenia was defined using body mass index- and sex-stratified thresholds optimally fit via a receiver-operating characteristic analysis for survival. Associations between preoperative sarcopenia and overall (OS), cancer-specific survival (CSS), and 90-day major complications were determined using multivariable analysis. 115 patients were analyzed, with median (IQR) age and body mass index of 69 (56-72) and 28.6 kg/m2 (23.6-32.9), respectively. 96 (83.4%) of the cohort had ccRCC. Sarcopenia was associated with shorter median OS (P=.0017) and CSS (P = .0019) in Kaplan-Meier analysis. In multivariable analysis, preoperative sarcopenia was prognostic of shorter OS (HR = 3.38, 95% confidence interval [CI] 1.61-7.09) and CSS (HR=5.15, 95% CI 1.46-18.18). Notably, 1 unit increases in SMI were associated with improved OS (HR = 0.97, 95% CI 0.94-0.999) but not CSS (HR=0.95, 95% CI 0.90-1.01). No significant relationship between preoperative sarcopenia and 90-day major surgical complications was observed in this cohort (HR=2.04, 95% CI 0.65-6.42). Preoperative sarcopenia was associated with decreased OS and CSS in patients surgically managed for nonmetastatic RCC and VTT, however, was not predictive of 90-day major postoperative complications. Body composition analysis has prognostic utility for patients with nonmetastatic RCC and venous tumor thrombus undergoing surgery.