Nephrectomy Type Research Articles

Partial Nephrectomy is Associated with Higher Risk of Relapse Compared with Radical Nephrectomy for Clinical Stage T1 Renal Cell Carcinoma Pathologically Up Staged to T3a

We studied recurrence-free survival after partial vs radical nephrectomy for clinical stage T1 renal cell carcinoma in all patients and in those up staged to pathological stage T3a. We retrospectively reviewed the records of 1,250 patients who underwent partial or radical nephrectomy for clinically localized T1 renal cell carcinoma between 2006 and 2014. Recurrence-free survival was estimated using the Kaplan-Meier method and evaluated as a function of nephrectomy type with the log rank test and Cox models, adjusting for clinical, radiological and pathological characteristics. A total of 86 recurrences (7%) were observed during a median followup of 37 months. No difference in recurrence-free survival between partial and radical nephrectomy was found among all clinical stage T1 renal cell carcinomas. T3a up staging was noted in 140 patients (11%) and recurrent disease was observed in 44 (31.4%) during a median followup of 38 months. Among up staged T3a cases partial nephrectomy was associated with shorter recurrence-free survival compared to radical nephrectomy on univariable analysis (recurrence HR 2.04, 95% CI 1.12-3.68, p = 0.019) and multivariable analysis (recurrence HR 5.39, 95% CI 1.94-14.9, p = 0.001). In a subgroup of patients clinically staged T1 renal cell carcinoma will be pathologically up staged to T3a. Among these patients those who undergo partial nephrectomy appear to have inferior recurrence-free survival relative to those who undergo radical nephrectomy.

Nephrectomy Type Was Not Associated with a Subsequent Risk of Coronary Heart Disease: A Population-Based Study.

Previous studies investigated the impacts of a partial nephrectomy (PN) or radical nephrectomy (RN) on cardiovascular events and death. However, the association between the type of nephrectomy (PN vs. RN) and cardiovascular disease is still equivocal. This retrospective cohort study aimed to compare the risk of coronary heart disease (CHD) between patients who underwent a PN and those who underwent an RN. We used data from the Taiwan Longitudinal Health Insurance Database 2005. In total, 60 patients who underwent a PN and 545 patients who underwent an RN were included. Each patient was tracked for 1-, 2-, 3-, and 5-year periods to identify those who were subsequently diagnosed with CHD. Cox proportional hazard regression analyses were used to calculate hazard ratios (HRs) for CHD during 1-, 2-, 3-, and 5-year follow-up periods between these two cohorts. For the 1-year follow-up period, the adjusted HR was 0.39 (95% CI: 0.05~2.90, p = 0.355) for patients who underwent a PN compared to those who underwent an RN. Additionally, the adjusted HRs of CHD in patients who underwent a PN for 2-, 3- and 5-year follow-up periods were 1.40 (95% CI: 0.62~3.16, p = 0.417), 1.09 (95% CI: 0.52~2.31, p = 0.814), and 1.02 (95% CI: 0.48~2.18, p = 0.961), respectively, compared to those who underwent an RN. We concluded that there was no significant difference in the risk of CHD between patients who underwent a PN and those who underwent an RN.

Validation of an Experimental Model to Study Less Severe Chronic Renal Failure

ABSTRACTPurpose: The 5/6 nephrectomy, mimics the stages of human chronic renal failure (CRF), but the procedure causes severe renal functional and morphological damage that could interfere with the evaluation of therapies for slowing the progression of the disease. This study summarizes the results of renal function, histology, and immunohistochemical findings in rats undergoing a 2/3 nephrectomy. Methods: The rats were distributed in groups according to the type of nephrectomy: CRF5/6: induced by a 5/6 renal mass reduction and CRF2/3: less severe CRF. The body weight and blood pressure were monitored, and the serum creatinine (SCr), creatinine clearance (CCr), urine osmolality, and 24-h proteinuria (PT24h) were measured. CRF progression was evaluated by the rate of decline of CCr (RCCr). Histology and immunohistochemistry were performed in the remnant kidneys. Statistical analysis was done by unpaired t-test, and a P-value < 0.05 was taken as a statistical significance. Results: Compared to the CRF5/6 group, the CRF2/3 model had a lower SCr, PT24h, CCr, and variations of the SCr from baseline. The disease progression was also significantly slower. The renal histopathological findings revealed fewer chronic lesions in rats with CRF2/3. Similarly, we observed less macrophage accumulation as well as lower proliferative activity and expression of fibronectin and a-smooth muscle-actin in the CRF2/3 model. Conclusions: The CRF2/3 model presented with a pattern of less severe CRF, functionally and morphologically, compared to the classical CRF5/6 model, and the CRF2/3 model may be useful for evaluating therapeutic interventions that target the early stages of CRF.

Perioperative factors associated with acute kidney injury after partial nephrectomy

BackgroundPartial nephrectomy is performed with the aim to preserve renal function. But the occurrence of postoperative acute kidney injury (AKI) can interfere with this goal. Our primary aim was to evaluate associations between pre-specified modifiable factors and estimated glomerular filtration rate after partial nephrectomy. Our secondary aims were to evaluate associations between pre-specified modifiable factors and both serum creatinine concentration and type of nephrectomy. MethodsThe records of 1955 patients who underwent partial nephrectomy were collected. Postoperative estimated glomerular filtration rate (eGFR) was used as the primary outcome measure. Twenty modifiable risk factors were studied. A repeated-measures linear model with autoregressive within-subject correlation structure was used. The interaction between all the factors and type of nephrectomy was also studied. ResultsA total of 1187 (61%) patients had no kidney injury, 647 (33%) had stage I, 80 (4%) had stage II, and 41 (2%) had stage III injury. The mean eGFR increased an estimated 0.83 (99.76% CI 0.79–0.88) ml min−1 1.73 m−2 for a unit increase in baseline eGFR. Mean eGFR was 2.65 (99.76% CI: 0.13, 5.18) ml min−1 1.73 m−2 lower in patients with hypertension. Mean eGFR decreased 0.42 (99.76% CI: 0.22, 0.62) ml min−1 1.73 m−2 for a 10-minute longer in duration of procedure and decreased 2.09 (99.76% CI: 1.39, 2.80) ml min−1 1.73 m−2 for a 10-minute longer in ischemia time. It was 3.53 (99.76% CI: 0.83, 6.23) ml min−1 1.73 m−2 lower for patients who received warm ischemia as compared to cold ischemia. ConclusionPotentially modifiable factors associated with AKI in the postoperative period were identified as baseline renal function, preoperative hypertension, longer duration of surgical time and ischaemia time, and warm ischaemia.

Nephron-sparing surgery across a nation - outcomes from the British Association of Urological Surgeons 2012 national partial nephrectomy audit.

To determine the scope and outcomes of nephron-sparing surgery (NSS), i.e. partial nephrectomy, across the UK and in so doing set a realistic benchmark and identify fresh contemporary challenges in NSS. In 2012 reporting of outcomes of all types of nephrectomy became mandatory in the UK. In all, 148 surgeons in 86 centres prospectively entered data on 6 042 nephrectomies undertaken in 2012. This study is a retrospective analysis of the NSS procedures in the dataset. A total of 1 044 NSS procedures were recorded and the median (range) surgical volume was 4 (1-39) per consultant and 8 (1-59) per centre. In all, 36 surgeons and 10 centres reported on only one NSS. The indications for NSS were: elective with a tumour of ≤4.5 cm in 59%, elective with a tumour of >4.5 cm in 10%, relative in 7%, imperative in 12%, Von Hippel-Lindau in 1%, and unknown in 11%. The median (range) tumour size was 3.4 (0.8-30) cm. The technique used was minimally invasive surgery in 42%, open in 58%, with conversions in 4%. The histology results were: malignant in 80%, benign in 18%, and unknown in 2%. In patients aged <40 years 36% (36/101) had benign histology vs 17% (151/874) of those aged ≥40 years (P < 0.01). In patients with tumours of <2.5 cm 29% (69/238) had benign histology vs 14% (57/410) with tumours of 2.5-4 cm vs 8% (16/194) with tumours of ≥4 cm (P = 0.02). In patients aged <40 years with of tumours of <2.5 cm 44% (15/34) were benign. The 30-day mortality was 0.1% (1/1 044). There were major complications (Clavien-Dindo grade of ≥IIIa) in 5% (53/1 044). There was an increased risk of complications after extended elective NSS of 19% (19/101) vs elective at 12% (76/621) (relative risk [RR] 1.54; P < 0.01). Margins were recorded in 68% (709/1 044) of the patients, with positive margins identified in 7% (51/709). Positive surgical margins after NSS for pathological T3 (pT3) tumours were found in 47.8% (11/23) vs 6.1% (32/523) for pT1a, tumours (RR 5.61; P < 0.01). In all, 14% (894/6 042) of the patients underwent surgery for T1a tumours: 55% (488/894) by NSS, 42% (377/894) by radical nephrectomy (RN), and in 3% (29/894) the procedure used was unknown. Major complications after occurred in 4.9% (24/488) of NSS vs 1.3% (5/377) of RN (P < 0.01). Limitations included poor reporting of renal function data and no data on tumour complexity. In its first year, mandatory national reporting has provided several challenging contemporary insights into NSS.

Survival analysis of surgically treated renal cell carcinoma: a single Chinese medical center experience from 2002 to 2012.

To analyze the survival and the associated factors affecting the prognosis of renal cell carcinoma (RCC) in China with a sufficiently large sample size. Clinical data with complete follow-up of 1326 RCC patients were successfully obtained. Progression-free survival (PFS) and cancer-specific survival (CSS) were calculated, survival analysis was performed by Kaplan-Meier analysis, and Cox proportional hazards regression models were served to estimate the prognostic significance of each variables. The median length of follow-up was 43.55 months (25-75 %, 25.47-68.75 months). During follow-up, 147 patients developed RCC-related progression, with a median PFS of 18.2 months (25-75 %, 7.50-47.27); 64 patients died from RCC-related progression, with a median CSS of 27.67 months (25-75 %, 14.10-58.53). For RCC patients in T1 stage, 3-, 5-, 8-, and 10-year CSS rates of patients receiving nephron-sparing nephrectomy were 99.33, 98.21, 97.40, and 97.40 %, respectively, which were significantly higher than radical nephrectomy patients (97.88, 96.28, 95.09, and 88.58 %, respectively). Cox proportional hazards regression model showed that tumor N stage, signs of lung metastasis (such as cough and hemoptysis), signs of bone metastasis (such as bone pain and fracture), pathological subtype of RCC, microscopic sarcomatoid change, and progression were prognosis factors for Chinese RCC patients. Tumor stage, nephrectomy type, lung metastasis, bone metastasis, pathological subtype, sarcomatoid change, and type of progression were important risk factors for RCC. For T1 stage RCC patients, nephron-sparing nephrectomy showed better CSS than radical nephrectomy, which may guide the doctors and patients in their choices of surgical procedures.

Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma: population-based and single-institutional analysis.

Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma is unclear. To assess whether PN provides adequate cancer control in high-risk disease (HRD), survival outcomes were compared in both a population-based cohort and an institutional cohort. Surveillance, Epidemiology, and End Results database and a prospectively maintained institutional database were queried for patients with RCC who underwent PN or RN for a localized tumor ≤7 cm and were found to have high-grade and/or high-stage disease (HRD). Cancer-specific (CSS) or recurrence-free survival (RFS) and overall survival (OS) were primary outcomes measured and were compared between those who underwent PN and RN using multivariable Cox proportional hazards and propensity analysis. The population cohort consisted of 12,757 (24.9 %) patients with HRD, 85.2 and 14.8 % of which underwent RN and PN, respectively. RN was not associated with CSS (HR 1.23, p = 0.08) but was independently associated with poor OS (HR 1.16, p = 0.031). Propensity analysis showed that RN resulted in a 20 % increased risk of death from all causes (p = 0.008). In the institutional cohort, of 317 patients, 35.9 % had HRD, 56 and 52 of which underwent RN and PN, respectively. Adjusting for age-adjusted Charlson index, RN was a predictor of poor OS (OR 6.20, p = 0.041). Propensity analysis showed that RFS and OS were not related to nephrectomy type (RN HR 0.65, p = 0.627 and RN HR 1.70, p = 0.484). In patients with pathologic high-risk RCC, partial excision is associated with similar cancer control as compared to radical excision.

Robustness of the 16-gene signature for prediction of recurrence-free interval in localized clear cell renal cell carcinoma.

455 Background: The Renal Cancer assay is a clinically validated RT-PCR assay developed to estimate the risk of recurrence in stage I-III clear cell renal cell carcinoma (ccRCC) patients (pts) treated with nephrectomy. The assay measures expression of 16 genes that are combined to calculate the Recurrence Score result (RS). The RS is associated with recurrence, renal cancer-specific survival and overall survival (all p&lt;0.001) (Escudier, ASCO 2014). The performance of the RS in clinically relevant subgroups, compared to the Leibovich score, and its within-patient variability was examined. Methods: The algorithm, endpoints, methods, and analysis plan were pre-specified prior to merging clinical and molecular data. RT-PCR of RNA from fixed paraffin-embedded ccRCC tissue was performed without knowledge of clinical data. Recurrence-free internval (RFI) was analyzed using Cox regression stratified by stage with data censored at 5 years, and Kaplan-Meier methods. Multivariable models incorporating the Leibovich score were used to assess the additional contribution of the RS to prediction of recurrence. Within- and between-tumor block reproducibility was assessed in an independent study using two separate tumor blocks from 8 pts, where each block was analyzed at 3 depths. Results: RS was generated in 626/645 pts (97%): 398 stage I, 54 stage II, 174 stage III. Median follow up was 5.5 yrs. The RS was significantly associated with risk of recurrence after adjustment for the Leibovich score (HR=4.20, p&lt;0.001). Additionally, the performance of RS was similar across age groups (&lt;60, 60-70 or ≥70), gender, nephrectomy type, tumor size (≤4, 4-7 or &gt;7cm), grade, and presence/absence of invasion (all interaction p&gt;0.29). Within-patient variability in the score (std. dev. of 1.73 and 4.74 RS units for within- and between-tumor block, respectively) was lower than patient-to-patient variability (std. dev. of 15.6 in validation study). Conclusions: The 16-gene signature remains strongly associated with risk of recurrence after adjustment for the Leibovich score and performs consistently across clinically relevant subgroups. Examination of within-patient and between-patient variability indicates that the score is robust to tumor heterogeneity.

Significance of Pathologic T3a Upstaging in Clinical T1 Renal Masses Undergoing Nephrectomy

BackgroundThe objectives of the present study were to report the incidence of pathologic T3a upstaging in a contemporary cohort of patients with clinical stage T1 (cT1) renal tumors treated with partial or radical nephrectomy; investigate the clinical outcomes; and identify the predictors associated with pathologic upstaging. Materials and MethodsFrom a single-institution, institutional review board–approved renal tumor database of 945 patients, we identified 610 patients who had undergone surgery for a cT1 renal mass. Data for 494 patients were available for analysis. Of these, 66 lesions had been pathologically upstaged to T3a after surgery and 428 had not. The oncologic follow-up data and clinical and pathologic features were recorded, and multivariable logistic regression analysis was performed to identify the risk factors for pT3a upstaging, controlling for age, gender, body mass index, and nephrectomy type. ResultsThe cT1 tumors of 66 patients (13.3%) were upstaged to pT3a after surgery. Of these 66 patients, 44 (66.7%) had undergone partial and 22 (33.3%) radical nephrectomy. The median follow-up period was 50 months. No patient with upstaging developed recurrence, and all were disease free at their last follow-up visit. On multivariable analysis, tumor size > 4 cm (odds ratio [OR], 3.766; 95% confidence interval [CI], 1.417-10.011; P < .008), clear cell histologic features (OR, 4.461; 95% CI, 1.498-13.461; P < .007), and positive surgical margins (hazard ratio, 5.118; 95% CI, 2.088-12.547; P < .0001) were associated with upstaging. ConclusionOf the cT1 lesions in 66 patients, 13% were pathologically upstaged after surgery. The patients with larger tumors, clear cell histologic features, and positive surgical margins were at the greatest risk of upstaging. However, after an intermediate follow-up period, pathologic upstaging did not appear to result in worsened oncologic outcomes.

Association of type of renal surgery and access to robotic technology for kidney cancer: results from a population‐based cohort

To evaluate the relationship between partial nephrectomy (PN) and hospital availability of robot-assisted surgery from a population-based cohort in the USA. After merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association survey from 2006 to 2008, we identified 21 179 patients who underwent either PN or radical nephrectomy (RN) for renal cell carcinoma (RCC). The primary outcome assessed was the type of nephrectomy performed. Multivariable logistic regression identified the patient and hospital characteristics associated with receipt of PN. We identified 4832 (22.8%) and 16 347 (77.2%) patients who were treated for RCC with PN and RN, respectively. On multivariable analysis, patients were more likely to receive PN at academic centres (odds ratio [OR] 2.77; P < 0.001), urban centres (OR 3.66; P < 0.001) and American College of Surgeons (ACOS)-designated cancer centres (OR: 1.10; P < 0.05) compared with non-academic, rural and non-ACOS-designated cancer centre hospitals, respectively. Robot-assisted surgery availability at a hospital was also associated with a higher adjusted odds of PN compared with centres without that availability (OR 1.28; P < 0.001). Although academic and urban locations are established factors that affect the receipt of PN for RCC, the availability of robot-assisted surgery at a hospital was also independently associated with higher use of PN. Our results are informative in identifying other key hospital characteristics which may facilitate greater adoption of PN.

Association of partial nephrectomy and presence of robotic surgery for kidney cancer in the United States.

484 Background: While hospital and surgeon characteristics are associated with the type of nephrectomy performed for renal cell carcinoma (RCC), it is unknown whether hospital presence of robotic surgery increases the likelihood of patients receiving partial nephrectomy (PN). Therefore, we evaluate the relationship of PN and hospital presence of robotic surgery from a population-based cohort in the U.S. Methods: After merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association (AHA) survey from 2006 to 2008, we identified 21,999 patients who underwent either PN or radical nephrectomy (RN) for RCC. The primary outcome of this study was the type of nephrectomy performed. Multivariable logistic regression was used to identify hospital characteristics associated with receipt of PN, after adjusting for patient case mix. Results: Overall, we identified 4,832 (22.0%) and 16,347 (88.0%) patients who were surgically treated for RCC with PN and RN, respectively. On multivariable analysis, patients undergoing surgery were more likely to receive PN at academic (OR: 2.77;p&lt;0.001), urban (OR: 3.66; p&lt;0.001), and American College of Surgeon (ACOS) designated cancer centers (OR: 1.10; p&lt;0.05) compared to non-academic, rural, and non-designated hospitals, respectively. After adjusting for patient and hospital characteristics, patients undergoing surgery at hospitals with presence of robotic surgery were also associated with higher adjusted odds ratios for receipt of PN compared to those treated at hospitals without the presence of this advanced treatment technology (OR: 1.28; p&lt;0.001). Conclusions: While academic status and urban locations are established characteristics influencing the type of nephrectomy performed for RCC, ACOS cancer center designation and hospital presence of robotic surgery were also associated with higher use of PN. Our results are informative in identifying key hospital characteristics which may facilitate greater adoption of PN.

The type of nephrectomy has little effect on overall survival or cardiac events in patients of 70 years and older with localized clinical t1 stage renal masses.

PurposeTo compare the outcomes of nephron-sparing options (e.g., partial nephrectomy [PN]) and low-surgical-morbidity options (e.g., radical nephrectomy [RN]) in elderly patients with limited life expectancy.Materials and MethodsWe retrospectively reviewed 135 patients aged 70 years or older who underwent RN (n=82) or PN (n=53) for clinical T1 stage renal masses between January 2000 and December 2012. Clinicopathologic data were thoroughly analyzed and compared between the RN and PN groups. The modification of diet in renal disease equation was used to estimate glomerular filtration. Overall survival and cardiac events were assessed by using Kaplan-Meier survival analysis and Cox proportional-hazards regression modeling.ResultsOver a median follow-up period of 59.72 months, 17 patients (20.7%) in the RN group and 3 patients (5.7%) in the PN group died. Chronic kidney disease (<60 mL/min/1.73 m2) developed more frequently in RN patients than in PN patients (75.6% vs. 41.5%, p<0.001). The 5-year overall survival rate did not differ significantly between the RN and PN groups (90.7% vs. 93.8%; p=0.158). According to the multivariate analysis, the Charlson comorbidity index score was an independent predictor of overall survival (hazard ratio [HR], 2.679, p=0.037). Type of nephrectomy was not significantly associated with overall survival (HR, 2.447; p=0.167) or cardiac events (HR, 1.147; p=0.718).ConclusionsAlthough chronic kidney disease was lower after PN, overall survival and cardiac events were similar regardless of type of nephrectomy.

Gender Disparity in Kidney Cancer Treatment: Women Are More Likely to Undergo Radical Excision of a Localized Renal Mass

To investigate gender effects on the type of nephrectomy performed for a stage I renal mass and differences that might account for disparity in treatment patterns according to gender. Using a single-institution database, patients who underwent nephrectomy at a tertiary referral center for a localized, solitary tumor, ≤ 7 cm with a normal contralateral kidney were identified. Variables thought to affect selection for type of nephrectomy were compared between male and female patients. Using multivariable logistic regression, the effect of gender on the likelihood of radical vs partial nephrectomy and the likelihood of malignancy were assessed. Renal function outcomes were also compared. No difference between genders was seen in age, race, smoking status, body mass index, tumor size, RENAL score or operating surgeon. Only Charlson index and preoperative creatinine significantly differed with women having a more favorable comorbidity profile (Charlson >1 in 38% vs 50%; P = .027) and lower mean preoperative creatinine (0.09 ± 0.3 vs 1.1 ± 0.3; P <.001). Despite lower creatinine, women had inferior preoperative renal function with a mean estimated glomerular filtration rate of 71.4 ± 21 vs 78.9 ± 21 mL/min/1.73 m2 in men (P <.001). Multivariable analysis indicated that female patients were 2.5 times more likely to undergo radical nephrectomy compared with their male counterparts (P = .022). Women were less likely to have malignancy (odds ratio male gender 2.50; P = .013). Women are more likely than men to undergo radical vs partial excision of a localized renal mass, despite less comorbid burden, inferior renal function, and increased likelihood of benign disease.

Partial and radical nephrectomy provide comparable long‐term cancer control for T1b renal cell carcinoma

To examine utilization rates of partial nephrectomy relative to radical nephrectomy for T1b renal cell carcinoma in contemporary years, to identify sociodemographic and disease characteristics associated with partial nephrectomy use, and to compare effectiveness of partial versus radical nephrectomy with respect to cancer control. Using the Surveillance, Epidemiology, and End Results database, 16,333 patients treated with partial or radical nephrectomy for T1bN0M0 renal cell carcinoma between 1988 and 2008 were identified. Logistic regression models were carried out to identify determinants of partial nephrectomy. Subsequently, cumulative incidence rates of cancer-specific and other-cause mortality between partial and radical nephrectomy were assessed, within the matched cohort. Furthermore, competing-risks regression analyses were used for prediction of cancer-specific mortality, after adjusting for other-cause mortality, and vice versa. The utilization rate of partial nephrectomy increased from 1.2% in 1988 to 15.9% in 2008 (P < 0.001). Younger individuals, smaller tumors, persons of black race, as well as men, were more likely to be treated with partial nephrectomy in the current cohort (all P ≤ 0.002). In the post-propensity cohort, the 5- and 10-year cancer-specific mortality rates were 4.4 and 6.1% for partial versus 6.0 and 10.4% for radical nephrectomy, respectively (P = 0.03). Competing-risks regression analyses showed that nephrectomy type was not statistically significantly associated with cancer-specific mortality, even after adjusting for other-cause mortality (hazard ratio 0.89, P = 0.5). Despite providing a comparable cancer control, the use of partial over radical nephrectomy for T1b renal cell carcinoma in USA has remained limited in recent years.

Prognostic factors of metastatic renal cell carcinoma with extensive sarcomatoid component

To evaluate clinical characteristics including the response to targeted therapy, the benefits of cytoreductive nephrectomy, or the prognostic factors in advanced renal cell carcinoma (RCC) with extensive sarcomatoid component (ESC), a rare but fatal disease. Data from 37 consecutive patients with metastatic or recurrent RCC with ESC (≥25 % on resected kidney or exclusive sarcomatoid histology on needle biopsy) were analyzed. Of the 37 patients, 27 patients (73 %) had synchronous metastatic disease. The median percentage of sarcomatoid component (PSC) was 50 % (range 25-93 %). Twenty (74 %) of the 27 synchronous metastatic patients underwent cytoreductive nephrectomy. Of the nine patients undergoing cytokine therapy, none showed objective responses. Two (15 %) of the 13 patients undergoing targeted agent therapy had partial responses, and five patients (38 %) achieved stable disease. The median overall survival for all patients was 5.9 months [95 % confidence interval (CI) 1.0-10.9]. In multivariate analysis, age (>58 years), ECOG performance status (>1), PSC (>50 %), and time from first diagnosis to advanced disease (<6 months) remained independent prognostic factors. Neither the type of systemic therapy nor cytoreductive nephrectomy had an effect on survival. Patients with RCC with ESC have a dismal clinical course, and the majority of patients have rapid disease progression, especially in response to immunotherapy. Four clinical factors can be used to model survival outcomes for advanced RCC with ESC and may be helpful in selecting patients for aggressive treatment.

Overall Survival and Development of Stage IV Chronic Kidney Disease in Patients Undergoing Partial and Radical Nephrectomy for Benign Renal Tumors

BackgroundAlthough partial nephrectomy (PN) has been associated with improved renal function compared with radical nephrectomy (RN) for renal cell carcinoma, the impact on overall survival (OS) remains controversial. ObjectiveTo evaluate comparative OS and renal function in patients following PN and RN for a renal mass where malignancy was not a confounding factor. Design, setting, and participantsUsing the Mayo Clinic Nephrectomy Registry, we retrospectively identified 442 patients with unilateral sporadic benign renal masses treated surgically with PN or RN between 1980 and 2008. Outcome measurements and statistical analysisThe primary outcome measures were OS and the incidence of new-onset stage IV chronic kidney disease (CKD), determined using the Kaplan-Meier method. Cox models were used to test the association of nephrectomy type with these outcomes. Results and limitationsOverall, 206 and 236 patients with benign renal masses were surgically treated with RN and PN, respectively. Patients who underwent RN were older (median age: 67 vs 64 yr; p=0.02) and had larger tumors (median size: 5.0 vs 2.7cm; p<0.001). Median follow-up for patients still alive at last follow-up was 8.3 yr (range: 0.1–27.9 yr). Estimated OS (95% confidence interval [CI]) rates at 10 and 15 yr were 69% (62–76%) and 53% (45–62%) for RN compared with 80% (73–87%) and 74% (65–83%) following PN (p=0.032). After adjusting for covariates of interest, patients treated with RN were significantly more likely to die from any cause (hazard ratio [HR]: 1.75; 95% CI, 1.08–2.83; p=0.023) or develop stage IV CKD (HR: 4.23; 95% CI, 1.80–9.93; p<0.001) compared with patients who underwent PN. Limitations include the retrospective design, selection bias for surgical approach, and referral bias to a tertiary care facility. ConclusionsOur data suggest that PN may confer a clinical benefit for improved renal function and better OS compared with RN after excluding the confounding effect of malignancy.

Oncologic kidney surgery in obese patients.

e15039 Background: Obesity adds significant operative challenge to kidney surgery. Its impact on minimally invasive kidney surgery has not been well defined. We evaluated the impact of obesity on open and minimally invasive kidney surgery (MIS) for kidney tumors. Methods: Patients in our prospectively collected IRB-approved kidney database were divided into 5 groups as determined by the World health organization Body mass index (BMI) classification: less than 25.0, 25.0-30.0, 30.0-35.0, 35.0-40.0, and more than 40.0 Kg/m2. Patient characteristics, and peri-operative data were recorded and compared between the different groups and between surgical approches(open vs. MIS) using the Kruskal Wallis and Chi Square tests for continuous and categorical data, respectively. The potential association between BMI and the continuous measures of OR time, Post op stay and EBL were assessed using spearman Correlations. Results: Of the 620 patients identified, 142 (22.9 %) had healthy weight, 180 (29.0%) were overweight, and 298 (48.1%) were obese. Most had grade 1 obesity (BMI 30-34, 167, 26.9%), grade 2 obesity (BMI 35-40, 76, 12.3%), and grade 3 obesity (BMI &gt; 40, 55, 8.9%). As expected, the ASA score rose with degree of obesity (p=&lt;.001). EBL (estimated blood loss), OR (operative time) time, Room time and post-operative stay differed significantly in the 5 groups of patients (p=0.001, p=0.003, p=&lt;0.002, p= &lt;.001, p=.002), respectively. While intra-operative complications did not differ between the obesity groups, obese patients had a higher rate of high grade Clavien complications (p=0.026). Interestingly, the surgical approach (open vs. MIS) and type of nephrectomy ( radical vs. partial) did not correlate with degree of obesity or complications, even when adjusted for stage. Conversion rates for MIS did not correlate with degree of obesity. Conclusions: Nephrectomy in obese patients results in incresed high grade of postoperative complications. Surgical approach does not appear to have any impact on peri-operative outcomes.

Partial versus radical nephrectomy in the elderly: A surgical conundrum.

e15046 Background: Whether increased risk of complication (Cx) is balanced by the renal preserving benefits of partial nephrectomy (PN) in those with shortened lifespan is unclear. We compared Cx and renal function outcomes of PN and radical nephrectomy (RN) in the elderly. Methods: From a prospectively maintained renal tumor database, we retrospectively identified patients ≥ 75 years old who had RN or PN for a solitary, localized tumor ≤ 7cm and a normal contralateral kidney. CKD-EPI formula estimated glomerular filtration rate (eGFR). Propensity analysis was used to account for population selection bias: probability of RN was calculated by multivariate logistic regression, including variables thought to influence selection for nephrectomy type, yielding a propensity score based on quintile of RN probability. Odds ratios for any Cx, high grade Cx and postoperative stage ≥ 4 chronic kidney disease [CKD4] by nephrectomy type were recalculated using logistic regression adjusting for propensity score. Other statistical tests used were Student′s t, Wilcoxon rank-sum and Fisher′s exact. Results: 57 patients met inclusion criteria: 47% and 53% had PN and RN, respectively. Age, gender, baseline Cr, BMI and Charlson index were similar between the PN and RN groups. In both groups, surgical approach was minimally invasive in 93%. Mean tumor size with RN was larger than with PN (4.6 v. 3.6 cm, p&lt;0.01). EBL was higher with PN (360 v. 122 mL, p=0.02), although intraoperative transfusion rate was similar (p=0.13). With similar preoperative eGFR between groups, mean postoperative eGFR was lower in the RN group (36 v. 50 ml/min/1.73m2, p&lt;0.01). Propensity analysis showed likelihood of CKD4 was significantly higher with RN (OR 5.5, p=0.04). Cx rate was similar between PN and RN (30% v.37%, p=0.39), but most high grade Cxs were seen with PN (56% v. 23%, p=0.01). Propensity analysis supported these data in that risk of total Cxs was not increased with PN (p=0.46) but risk of high grade Cxs was significantly higher with PN (OR 9.2, p&lt;0.01). Conclusions: Risk of significant renal dysfunction following RN was 5-fold that of PN, but risk of high grade complications with PN is 9-fold that of RN. Evaluating the clinical impact of these risks should be done on an individual patient basis.

Effect of total and partial nephrectomy on the elimination of ciprofloxacin in humans

BackgroundRenal cell carcinoma (RCC) is the most common form of kidney cancer. Surgery is a standard procedure to resect the tumor during total (TN) or partial (nephron-sparing) nephrectomy (PN). Ciprofloxacin is most often administered at the usual intravenous dose of 100–400mg/12h. The application of such low doses of ciprofloxacin as 200mg/24h carries the risk of achieving subtherapeutic concentrations even in patients with limited renal function. The aim of the study was a comparison of concentrations and pharmacokinetics for ciprofloxacin at steady-state in patients after total and partial nephrectomy and evaluation of the effectiveness of the iv dose 200mg/24h against the theoretical value of MIC, 0.5μg/ml. MethodsThe research was carried out on two groups of patients after nephrectomy: total (group 1, n=21; mean [SD], age, 62.9 [14.4] years; weight, 76.0 [14.6]kg; creatinine clearance, clcr, 90.7 [22.2]ml/min) and partial (group 2, n=15; 61.7 [9.3] years; 87.8 [16.4]kg; CLCR, 107.8 [36.4]ml/min). The patients were treated with ciprofloxacin in the dose of 200mg/24h (iv). Plasma concentrations of ciprofloxacin at steady state were measured with validated HPLC method with UV detection. ResultsThe mean values of plasma concentrations of ciprofloxacin at steady state in group 1 and 2 were: Cssmax, 2.012 and 1.345; Cssmin, 0.437 and 0.244μg/ml, respectively. The main pharmacokinetic parameters for ciprofloxacin in group 1 and 2 were as follows: AUC(0–last), 30.9 [17.9] and 19.5 [8.7]μgh/ml; AUMC(0–last), 177.91 [11.1] and 91.9 [66.5]μgh2/ml; t1/2β, 13.9 [7.7] and 9.8 [3.3]h; MRT, 16.5 [12.1] and 9.77 [5.4]h; Vd, 115.0 [67.2] and 142.2 [78.7]l; CL, 6.2 [3.3] and 10.8 [5.7]l/h, respectively. With the assumed MIC=0.5μg/ml, the values of Cssmax/MIC<10 and AUC/MIC<125 were obtained in all the patients. ConclusionIn our patients we observed significant differences in some pharmacokinetic parameters of ciprofloxacin after two types of nephrectomy.

709 OLDER AND SICKER RENAL CELL CARCINOMA PATIENTS ARE OPERATED AT LOW VOLUME HOSPITALS

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging II1 Apr 2012709 OLDER AND SICKER RENAL CELL CARCINOMA PATIENTS ARE OPERATED AT LOW VOLUME HOSPITALS Maxine Sun, Quoc-Dien Trinh, Marco Bianchi, Jens Hansen, Nawar Hanna, Zhe Tian, Shahrokh Shariat, Paul Perrotte, and Pierre Karakiewicz Maxine SunMaxine Sun Montreal, Canada More articles by this author , Quoc-Dien TrinhQuoc-Dien Trinh Detroit, MI More articles by this author , Marco BianchiMarco Bianchi Milan, Italy More articles by this author , Jens HansenJens Hansen Hamburg, Germany More articles by this author , Nawar HannaNawar Hanna Montreal, Canada More articles by this author , Zhe TianZhe Tian Montreal, Canada More articles by this author , Shahrokh ShariatShahrokh Shariat New York, NY More articles by this author , Paul PerrottePaul Perrotte Montreal, Canada More articles by this author , and Pierre KarakiewiczPierre Karakiewicz Montreal, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.793AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Hospital volume represents an established determinant of outcomes. We sought to examine the patient selection for surgical candidates according to hospital volume, using patient age and baseline comorbidities as proxies. METHODS Overall, 48172 non-metastatic renal cell carcinoma (RCC) patients were identified amongst 2084 hospitals originating from the Nationwide Inpatient Sample, between years 1998 and 2007. We examined patient age, baseline Charlson comorbidity index (CCI), gender, race, nephrectomy type, hospital teaching status, hospital region, and surgical approach (open vs. laparoscopic) according to hospital volume, which was modeled in a continuously coded fashion. Finally, we examined the effect of hospital volume on patient age and CCI, using linear regression analyses. Adjustment was made for all the aforementioned covariates. RESULTS The overall mean hospital volume was 16 nephrectomies per year (median 9, interquartile range [IQR]: 4–20). First, hospital volume decreased with increasing patient age (≤59 years mean: 17 (median 9) vs. ≥80 years: 13 (median 8), P<0.001) and increasing CCI (0 mean: 16 (median 9) vs. ≥3: 13 (median 8), P<0.001). The effect of hospital volume also differed according to gender, nephrectomy type, hospital teaching status, hospital region, and surgical approach. Specifically, females, patients of Hispanic race, radical nephrectomies, non-teaching hospitals, hospitals located in the West, and cases performed via the open approach were more likely to be of low hospital volume. In univariable linear regression analyses, decreasing age (beta: -0.044, P<0.001) and decreasing CCI (beta: -0.027, P<0.001) was inversely associated with increasing hospital volume. These findings were confirmed in multivariable analyses, where patients with increasing age (beta: -3.512, P<0.001) and higher CCI (beta: -3.896, P<0.001) were more likely to be operated at hospitals with a low hospital volume. CONCLUSIONS Individuals of more advanced age and those with multiple comorbidities tend to be treated at low hospital volume institutions. Such practice may lead to less favorable outcomes in those individuals. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e290-e291 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Maxine Sun Montreal, Canada More articles by this author Quoc-Dien Trinh Detroit, MI More articles by this author Marco Bianchi Milan, Italy More articles by this author Jens Hansen Hamburg, Germany More articles by this author Nawar Hanna Montreal, Canada More articles by this author Zhe Tian Montreal, Canada More articles by this author Shahrokh Shariat New York, NY More articles by this author Paul Perrotte Montreal, Canada More articles by this author Pierre Karakiewicz Montreal, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...