Charles Field

Renal Functional Outcome of Partial Nephrectomy for Complex R.E.N.A.L. Score Tumors With or Without Neoadjuvant Sunitinib: A Multicenter Analysis

Background Sunitinib might optimize the feasibility of partial nephrectomy (PN) for complex renal tumors with imperative indications. We compared the renal functional outcomes of patients with complex renal masses who had undergone sunitinib before PN with those of patients who had not required neoadjuvant sunitinib before PN. Patients and Methods We performed a multicenter retrospective analysis of patients with renal cell carcinoma who had undergone PN for a complex renal mass (R.E.N.A.L. nephrometry score, 10‐12) and imperative indications from January 2012 to July 2014. Neoadjuvant sunitinib was used in cases for which PN was not considered feasible. The cohort was divided into those patients who had undergone PN without neoadjuvant sunitinib and those who had undergone PN after sunitinib (no‐neoadjuvant vs. neoadjuvant). The change in tumor size and R.E.N.A.L. score were assessed. The primary outcome was the change in the estimated glomerular filtration rate (&Dgr;eGFR) from preoperatively to the last postoperative follow‐up visit. Results The data from 125 consecutive patients were analyzed (47 neoadjuvant and 78 no‐neoadjuvant; median follow‐up, 21 months). The neoadjuvant plus PN patients had had a greater median tumor size preoperatively (7.2 vs. 6 cm; P = .045). Sunitinib caused a significant decrease in the median tumor size (from 7.2 to 5.8 cm [19.4%]; P = .012) and R.E.N.A.L. score (from 11 to 9; P = .001). No significant differences were found between the neoadjuvant and no‐neoadjuvant groups in the ischemia time (P = .413) or incidence of complications (P = .728). The median &Dgr;eGFR was similar (neoadjuvant, 6.4; no‐neoadjuvant, 6.1; P = .534). Linear regression analysis for factors associated with an increasing &Dgr;eGFR demonstrated increasing age (estimate, −0.074; P = .009) increasing body mass index (estimate, −0.087; P = .043), and decreasing baseline eGFR (estimate, −0.104; P = .02) as significant factors. Conclusion The use of neoadjuvant sunitinib might facilitate complex PN and result in renal functional outcomes similar to those of patients with a complex renal mass who had not required neoadjuvant sunitinib. Micro‐Abstract Neoadjuvant sunitinib might facilitate partial nephrectomy (PN) in imperative indications. We performed a retrospective comparison of functional outcomes in patients who had and had not received neoadjuvant sunitinib before PN for imperative indications. We noted similar renal functional outcomes between the 2 groups. To the best of our knowledge, these findings represent the first such reported comparison.

MP72-09 TRENDS IN UTILIZATION AND QUALITY OUTCOMES OF PARTIAL NEPHRECTOMY IN CT1B AND CT2A RENAL CELL CARCINOMA: ANALYSIS OF THE NATIONAL CANCER DATABASE

laparoscopic kidney tumor enucleation. The tumor bed parenchyma of 15 mm beyond the pseudocapsule were continuously sectioned and examined to investigate the possible presence of tumor invasion or satellite lesions. RESULTS: The study involved 246 patients, consisting of 148 men (60.2%) and 98 women (39.8%), with a mean age of 60.9 10.3 years. The average tumor size was 5.3 1.7 cm. The histopathologic evaluation revealed that 82.5% of tumors were clear cell RCC, 7.7% were papillary, and 6.5% were chromophobe. The pathological staging showed that 23.2% of tumors were pT1a, 68.3% were pT1b, 3.7% were pT2, and 4.9% were pT3a. On the basis of Fuhrman nuclear grading, 171 lesions (69.5%) were grade 1-2 and 75 (30.5%) were grade 3-4. The incidence of positive surgical margins was 3.3%. For the pathological characteristics of tumor bed, tumor infiltration was detected in 5 cases (2.0%) and satellite lesion was detected in 4 cases (1.6%). In the group of 60 primary tumors 4 cm or less in diameter, 3 (5.0%) were found with residual tumor, 1 with tumor infiltration and 2 with satellite lesion. In the group of 186 primary tumors larger than 4 cm, 6 (3.2%) were found with residual tumor, 4 with tumor infiltration and 2 with satellite lesion. Statistically, there was no significant difference (p1⁄40.809). In the group of grade 1-2, 4 (2.3%) were found with residual tumor, and 5 (6.7%) in the group of grade 3-4 (p1⁄40.195). Median followup was 24 months (range 8-43) with a recurrence rate of 4.1% (10 of 246) and a cancer specific mortality rate of 2.4% (6 of 246). CONCLUSIONS: The risks of tumor infiltration and/or satellite lesions of enucleation tumor bed are relatively low. Tumor enucleation is a histopathologically safe technique for patients undergoing partial nephrectomy.

PD20-07 ONCOLOGIC AND SURVIVAL OUTCOMES FOR PATHOLOGIC T3A UPSTAGING IN CLINICALLY LOCALIZED RENAL MASSES: DOES PARTIAL NEPHRECTOMY INCREASE ONCOLOGICAL RISK?

continuous and categorical variables, respectively. Outcomes of interest includedestimatedblood loss,warm ischemia time, estimatedglomerular filtration rate at 6 months, length of stay, margin status, Fuhrman grade, tumor size, pathological histology, and symptoms index at presentation RESULTS: Among our cohort, 376 (62%) and 228 (38%) patients with were scheduled for RN and PN, respectively. Of the 228 patients originally scheduled for PN, 12% were converted to RN intraoperatively. A smaller proportion of patients scheduled to undergo PN had clear cell/conventional histology (77% vs 88%; p1⁄40.001) on pathology compared to patients scheduled for RN. Among patients with clear cell or papillary histology, a larger proportion of patients scheduled for PN had lower Fuhrman grade (24% vs 10.3% had FG 1 or 2; p<0.0001) on pathology than patients scheduled for RN. Of our 604 patients, 111 patients died, 33 from kidney disease. The median follow up time for survivors was 2.0 years from surgery. On multivariable analysis, scheduled PN was non-significantly associated with better OS (HR 0.62; 95% C.I. 0.37, 1.03; p 1⁄4 0.064), better CSS (HR 0.51; 95% C.I. 0.18, 1.49; p 1⁄4 0.2), and better RFS (HR 0.56; 95% C.I. 0.29, 1.07; p1⁄40.081). From the estimates of the hazard ratio, we suspect that the bias related to surgeons choosing PN or RN based on low or high risk disease is not appropriately adjusted for in our model CONCLUSIONS: We found no evidence to suggest that PN has poorer outcomes than RN in patients with pT3a tumors. The inherent benefits of PN on renal function preservation make this approach very attractive even in larger and complex tumors

MP67-07 PATHOLOGICAL DETERMINANTS OF ONCOLOGIC OUTCOMES IN STAGE II RENAL CELL CARCINOMA: AN INTERNATIONAL MULTICENTER ANALYSIS

bilateral kidneys with single eAML on the left). Only one patient suffered from spontaneous haemorrhage. Two cases developed distant metastasis: one had nodules over bilateral lungs and left anterior mediastinum; the other had recurrence over liver and retroperitoneum one year after surgical intervention. Three cases had venous thrombus (two in renal vein and one in inferior vena cava) and received thrombectomy. All 21 cases received surgical intervention: 13 radical nephrectomy, 7 partial nephrectomy, one was found with retroperitoneal eAML arising from renal capsule thus undergone tumor excision without kidney involvement. The follow up period ranges from 1 to 143 months (average 51 months). Only 2 cases died from unrelated cause. CONCLUSIONS: In our study, the rate of aggressive behavior is 24% (2 distant metastasis and 3 venous invasion in the 21 cases). Some noticeable accompanying characteristics including haemorrhage, coexisting with AML, coexisting with renal cell carcinoma are also seen in this series. The incidence of renal vein and inferior vena cava thrombus formation in our series is high (3 out of 21), therefore, detailed preoperative image evaluation is necessary.

MP72-03 COMPARATIVE ANALYSIS OF RADICAL AND PARTIAL NEPHRECTOMY IN PATIENTS WITH PREOPERATIVE STAGE 2 CHRONIC KIDNEY DISEASE: A MULTICENTER STUDY

Zachary Hamilton*, San Diego, CA; Alessandro Larcher, Milan, Italy; Brian Lane, Grand Rapids, MI; Umberto Capitanio, Milan, Italy; Sumi Dey, Grand Rapids, MI; Aaron Bloch, Charles Field, San Diego, CA; Samer Kirmiz, Grand Rapids, MI; Daniel Han, San Diego, CA; Adam Bezinque, Grand Rapids, MI; Alp Tuna Beksac, San Diego, CA; Cristina Carenzi, Milan, Italy; Fang Wan, James Proudfoot, San Diego, CA; Francesco Montorsi, Milan, Italy; Ithaar Derweesh, San Diego, CA

PD73-07 ANALYSIS OF RISK FACTORS ASSOCIATED WITH INFECTIONS COMPLICATIONS FOLLOWING PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: The duration of renal ischemia is the largest modifiable risk factor during partial nephrectomy. The shorter the warm ischemia time during LPN the lower the effect on long-term renal function. Real advantages of offclamping LPN compared with clamping surgery are not yet sufficiently studied. Few studies reported results of off-clamping LPN for high RENAL score cases. We compared Trifecta outcomes of the LPN with and without clamping stratifying cases through nephrometric RENAL score. METHODS: A total of 109 cases classified as low-complexity (54), intermediate-complexity (33) and high-complexity (22) underwent clamping (55) or off-clamping (54) laparoscopic partial nephrectomy and were compared in each group (clamping x off-clamping LPN). Clamping technique was performed with cold scissors intended to obtain 0.5cm of free surgical margins. Off-clamp technique was performed with harmonic scalpel close to the plane of enucleating to achieve minimal surgical margins. Renal function was measured at 1, 6 and 12 months postoperatively. All enrolled patients had normal contralateral kidney. Trifecta (Trifecta criteria: Clavien 2, negative-margins, and warm ischemia time 20 min) outcomes were analyzed and compared between the groups stratified by the nephrometric RENAL score. RESULTS: Trifecta achievement was similar in both groups for low complexity tumors (p < 0.31). The off-clamping group achieved higher trifecta rates for the intermediate (87.5% x 23.5%, p < 0.001) and high (83% x 0%, p < 0.005) complexity tumors. Patients with off-clamp technique had higher mean blood loss (150 X 400 ml) with no difference in blood transfusions. In the clamping group, significant higher proportion did not achieve trifecta (45.5% x 7.4%, p < 0.001). After 1 year, the difference of remnant renal function was 10% more for patients with off clamp surgery with high complexity RENAL score CONCLUSIONS: Off-clamping pure LPN was associated to accomplish higher trifecta rates for intermediate and high complexity RENAL score tumors. Long-term renal function was slightly better for off clamp group. It is unclear if off-clamp technique or differences in the amount resected of renal parenchyma were responsible for observed differences.

Comparison of laparoendoscopic single-site (LESS) and multiport laparoscopic radical nephrectomy for clinical T1b and T2a renal masses.

BACKGROUND The aim of this study was to compare outcomes of laparoendoscopic single-site surgery (LESS) and multiport laparoscopic (MPL) radical nephrectomy (RN) for clinical T1b/T2a renal masses, as concerns continue regarding suitability and benefit of LESS for larger renal masses. METHODS Retrospective single-surgeon comparison of LESS- and MPL-RN between 7/2005 and 11/2014. Sixty-three patients underwent LESS-RN (44 cT1b/19 cT2a); 133 underwent MPL (83 cT1b/50 cT2a). All patients were managed with a standardized care pathway. Primary outcome was length of hospital stay (LOS). Secondary outcomes included operative time, estimated blood loss (EBL), complications, discharge pain score (visual analog pain, VAP), narcotic requirement (morphine equivalents, MSO4eq). RESULTS 130/133 MPL and 62/63 LESS were successfully performed. For MPL and LESS groups: mean tumor diameter (cm) for cT1b was 5.3 vs. 5.4 (P=0.689); and for cT2a was 8.2 vs. 8.3 (P=0.728); mean OR time (min) was 126.3 vs. 132.7 (P=0.314); mean EBL (mL) was 139.5 vs.127.8 (P=0.49). No significant differences in complications were noted (P=0.781). LESS was associated with significant reductions in LOS (2.14 vs. 2.45 days, P=0.043), discharge VAP (1.3 vs. 2.2, P<0.001), and narcotic use (5.9 vs. 10.7 MSO4eq, P<0.001). CONCLUSIONS LESS is comparable to MPL-RN for cT1b and T2a renal tumors in terms of perioperative parameters and may confer benefit with respect to LOS and analgesic requirement.