Daniel Canter

Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis.

The authors systematically reviewed the literature and conducted a pooled analysis of studies on small renal masses who underwent active surveillance to identify the risk progression and the characteristics associated with metastases.

Objective Measures of Renal Mass Anatomic Complexity Predict Rates of Major Complications Following Partial Nephrectomy

BACKGROUND The association between tumor complexity and postoperative complications after partial nephrectomy (PN) has not been well characterized. OBJECTIVE We evaluated whether increasing renal tumor complexity, quantitated by nephrometry score (NS), is associated with increased complication rates following PN using the Clavien-Dindo classification system (CCS). DESIGN, SETTING, AND PARTICIPANTS We queried our prospectively maintained kidney cancer database for patients undergoing PN from 2007 to 2010 for whom NS was available. INTERVENTIONS All patients underwent PN. MEASUREMENTS Tumors were categorized into low- (NS: 4-6), moderate- (NS: 7-9), and high-complexity (NS: 10-12) lesions. Complication rates within 30 d were graded (CCS: I-5), stratified as minor (CCS: I or 2) or major (CCS: 3-5), and compared between groups. RESULTS AND LIMITATIONS A total of 390 patients (mean age: 58.0 ± 11.9 yr; 66.9% male) undergoing PN (44.6% open, 55.4% robotic) for low- (28%), moderate- (55.6%), and high-complexity (16.4%) tumors (mean tumor size: 3.74 ± 2.4 cm; median: 3.2 cm) from 2007 to 2010 were identified. Tumor size, estimated blood loss, and ischemia time all significantly differed (p<0.0001) between groups; patient age, body mass index (BMI), and operative time were comparable. When stratified by CCS, minor and major complication rates for all patients were 26.7% and 11.5%, respectively. Minor complication rates were comparable (26.6 vs. 24.9 vs 32.8%; p=0.45), whereas major complication rates differed (6.4 vs. 11.1 vs. 21.9%; p=0.009) among tumor complexity groups. Controlling for age, gender, BMI, type of surgical approach, operative duration, and tumor complexity, prolonged operative time (odds ratio [OR]: 1.01; confidence interval [CI], 1.0-1.02) and high tumor complexity (OR: 5.4; CI, 1.2-24.2) were associated with the postoperative development of a major complication. Lack of external validation is a limitation of this study. CONCLUSIONS Increasing tumor complexity is associated with the development of major complications after PN. This association should be validated externally and integrated into the decision-making process when counseling patients with complex renal tumors.

Anatomic Features of Enhancing Renal Masses Predict Malignant and High-Grade Pathology: A Preoperative Nomogram Using the RENAL Nephrometry Score

BACKGROUND Counseling patients with enhancing renal mass currently occurs in the context of significant uncertainty regarding tumor pathology. OBJECTIVE We evaluated whether radiographic features of renal masses could predict tumor pathology and developed a comprehensive nomogram to quantitate the likelihood of malignancy and high-grade pathology based on these features. DESIGN, SETTING, AND PARTICIPANTS We retrospectively queried Fox Chase Cancer Centers prospectively maintained database for consecutive renal masses where a Nephrometry score was available. INTERVENTION All patients in the cohort underwent either partial or radical nephrectomy. MEASUREMENTS The individual components of Nephrometry were compared with histology and grade of resected tumors. We used multiple logistic regression to develop nomograms predicting the malignancy of tumors and likelihood of high-grade disease among malignant tumors. RESULTS AND LIMITATIONS Nephrometry score was available for 525 of 1750 renal masses. Nephrometry score correlated with both tumor grade (p < 0.0001) and histology (p < 0.0001), such that small endophytic nonhilar tumors were more likely to represent benign pathology. Conversely, large interpolar and hilar tumors more often represented high-grade cancers. The resulting nomogram from these data offers a useful tool for the preoperative prediction of tumor histology (area under the curve [AUC]: 0.76) and grade (AUC: 0.73). The model was subjected to out-of-sample cross-validation; however, lack of external validation is a limitation of the study. CONCLUSIONS The current study is the first to objectify the relationship between tumor anatomy and pathology. Using the Nephrometry score, we developed a tool to quantitate the preoperative likelihood of malignant and high-grade pathology of an enhancing renal mass.

Pediatric Flexible Ureteroscopic Lithotripsy: The Children's Hospital of Philadelphia Experience

PURPOSE Therapeutic options currently available for urinary stones include shock wave lithotripsy, percutaneous nephrolithotomy and ureteroscopic treatment. While these treatment options have become the standard of care in the adult population, the same has not necessarily been applied to the pediatric population, despite an increasing prevalence of stone disease in children. We report our flexible ureteroscopic experience with urinary stones in children. MATERIALS AND METHODS A total of 170 ureteroscopic treatments were performed. Demographic information was collected. Stone burden was measured in millimeters. Operative access, operative times, intraoperative complications, stone-free status and postoperative complications were evaluated. RESULTS A total of 167 children (89 boys and 78 girls) underwent 170 ureteroscopic procedures for urinary calculi. Mean patient age was 62.4 months at the time of the procedure (range 3 to 218). Mean followup was 19.7 months (range 6 to 39). Mean stone burden was 6.12 mm (range 3 to 24), with an average of 1.3 stones per patient. Retrograde access could not be obtained in 95 of the children (57%). No ureters were actively dilated. Flexible ureteroscopy was performed in all cases regardless of stone location. Stone clearance was 100% for stone burdens 10 mm or less and 97% for burdens greater than 10 mm after 1 ureteroscopy. CONCLUSIONS Pediatric ureteroscopy is a safe and efficacious modality in the treatment of all upper urinary tract calculi, including lower pole calculi.

Utility of the R.E.N.A.L. Nephrometry Scoring System in Objectifying Treatment Decision-making of the Enhancing Renal Mass

OBJECTIVE To evaluate the treatment patterns of solid renal masses according to the quantifiable anatomic features using nephrometry. The treatment of localized renal cell carcinoma remains overly subjective. The R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior, location relative to polar lines) nephrometry score quantifies the salient characteristics of renal mass anatomy in an objective and reproducible manner. METHODS Nephrometry scores were available in 615 patients in our prospective kidney tumor database (2000-2010). The nephrometry score sum and its individual component scores were analyzed to determine their relationship to treatment approach. RESULTS The median age, age-adjusted Charlson co-morbidity index, and estimated glomerular filtration rate was 60 years (range 25-89), 2 (range 0-10), and 80.5 mL/min (range 5.1-120.0), respectively. Increasing tumor complexity, as measured by a greater overall nephrometry score was associated with both radical nephrectomy and open partial nephrectomy (P < .0001). Compared with patients who underwent partial nephrectomy, the patients treated with radical nephrectomy had a significantly greater size (R), central proximity (N), and location (L) component scores (P < .001). Furthermore, tumors treated with radical nephrectomy were more often hilar (P < .001). Similarly, compared with minimally invasive partial nephrectomy (laparoscopic or robotic), open partial nephrectomy was associated with an increasing individual component score for size, endophytic, and central proximity to the collecting system (P < .001) and nonpolar location (P = .016). CONCLUSION The R.E.N.A.L nephrometry score standardizes the reporting of solid renal masses and appears to effectively stratify by treatment type. Although only 1 part of the treatment decision-making process, nephrometry aids in objectifying previously subjective measures.

Perioperative Outcomes of Robotic and Open Partial Nephrectomy for Moderately and Highly Complex Renal Lesions

PURPOSE We compared outcomes in patients undergoing robotic vs open partial nephrectomy stratified by moderately and highly complex tumor nephrometry scores. MATERIALS AND METHODS Patients treated with partial nephrectomy from 2007 to 2010 were grouped by tumor characteristics into low-nephrotomy score 4 to 6, moderate-7 to 9 and high-10 to 12 anatomical complexity cohorts. Lesions with low complexity were excluded from study. Demographic, surgical and pathological outcomes were compared between patients undergoing robotic vs open partial nephrectomy in the moderately and highly complex cohorts. RESULTS A total of 281 patients, of whom 63.3% were male, with a mean±SD age of 58.1±11.7 years and a mean followup of 21.3±16.3 months underwent partial nephrectomy. Moderately complex lesions were noted in 81 robotic and 136 open partial nephrectomy cases with a mean tumor size of 3.8±2.2 cm. Highly complex lesions were noted in 10 robotic and 54 open partial nephrectomy cases with a mean tumor size of 4.8±3.0 cm. There were no differences between the groups in patient age, race, gender, body mass index or American Society of Anesthesiologists classification. Cases treated with open partial nephrectomy for moderately or highly complex lesions were of higher pathological stage (p=0.02 and 0.01, respectively). The percent change in creatinine and the glomerular filtration rate were similar for robotic and open partial nephrectomy in the moderately and highly complex tumor groups. In patients undergoing robotic vs open partial nephrectomy for moderately complex lesions we noted differences in pathological tumor size (mean 3.2±1.8 vs 4.1±2.3 cm, p<0.0001) and operative time (205.9±52.5 vs 189.5±52.0 minutes, p<0.01) while decreased estimated blood loss (131.3±127.8 vs 256.5±291.3 ml) and hospital length of stay (3.7±1.6 vs 5.6±3.9 days, each p<0.001) were observed in the robotic group. Comparison of highly complex lesions revealed decreased hospital length of stay (2.9±1.4 vs 6.1±4.1 days, p<0.0001) in the robotic partial nephrectomy group. CONCLUSIONS In our large institutional series of patients with moderate and highly complex solid renal tumors classified by the nephrometry score robotic partial nephrectomy offered comparable perioperative and functional outcomes with the added benefit of decreased hospital length of stay.

Partial nephrectomy for renal masses ≥ 7 cm: technical, oncological and functional outcomes.

Whats known on the subject? and What does the study add?

Competing Risks of Death in Patients with Localized Renal Cell Carcinoma: A Comorbidity Based Model

PURPOSE Multiple risks compete with cancer as the primary cause of death. These factors must be considered against the benefits of treatment. We constructed a model of competing causes of death to help contextualize treatment trade-off analyses in patients with localized renal cell carcinoma. MATERIALS AND METHODS We identified 6,655 individuals 66 years old or older with localized renal cell carcinoma in the linked SEER (Surveillance, Epidemiology and End Results)-Medicare data set for 1995 to 2005. We used Fine and Gray competing risks proportional hazards regression to predict probabilities of competing mortality outcomes. Prognostic markers included race, gender, tumor size, age and the Charlson comorbidity index score. RESULTS At a median followup of 43 months, age and comorbidity score strongly correlated with patient mortality and were most predictive of nonkidney cancer death, as measured by concordance statistics. Patients with localized, node negative kidney cancer had a low 3 (4.7%), 5 (7.5%) and 10-year (11.9%) probability of cancer specific death but a significantly higher overall risk of death from competing causes within 3 (10.9%), 5 (20.1%) and 10 years (44.4%) of renal cell carcinoma diagnosis, depending on comorbidity score. CONCLUSIONS Informed treatment decisions regarding patients with solid tumors must integrate not only cancer related variables but also factors that predict noncancer death. We established a comorbidity based predictive model that may assist in patient counseling by allowing quantification and comparison of competing risks of death in patients 66 years old or older with localized renal cell carcinoma who elect to proceed with surgery.

Assessing Performance Trends in Laparoscopic Nephrectomy and Nephron-sparing Surgery for Localized Renal Tumors

OBJECTIVE To assess the impact of laparoscopy on usage of partial nephrectomy (PN) by comparing national usage trends in patients undergoing surgery for localized renal tumors. METHODS Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we retrospectively examined trends in procedure usage from 1995 to 2007 for patients undergoing surgery for localized (stage I/II) renal masses. Procedures were classified as open radical nephrectomy (ORN), laparoscopic radical nephrectomy (LRN), open partial nephrectomy (OPN), and laparoscopic partial nephrectomy (LPN). Patients were further stratified by tumor size (≤4 cm, >4- ≤7 cm, >7 cm). Data were primarily analyzed using logistic regressions. RESULTS Patients (n = 11,689, mean age 74.4 ± 5.7 years, 56% male) with a mean tumor size of 4.7 ± 3.3 cm met the inclusion criteria. From 1995 to 2007, ORN rates decreased and for each year successive year patients were more likely to be treated with OPN (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.14-1.19), LRN (OR 1.44, CI 1.41-1.47), and LPN (OR 1.75, CI 1.68-1.83). Although the increased usage of OPN (7.5% vs 13.6%, P < .001) and LPN (0% vs 14.2%, P < .001) reached statistical significance, this was offset by a marked increase in LRN over the same time period (3.0% vs 43.0%, P < .001). CONCLUSION Despite increasing emphasis on nephron preservation, PN usage rates remain low. Compared with a 40% increase in LRN, use of PN increased by only 20% from 1995 to 2007. As a result, 72% of identified Medicare beneficiaries with localized tumors were managed with radical nephrectomy (RN) in 2007. The trade-off of minimally invasive surgery for nephron preservation may have adverse long-term consequences.

Clinicopathological outcomes after radical cystectomy for clinical T2 urothelial carcinoma: further evidence to support the use of neoadjuvant chemotherapy

Study Type – Therapy (case series)
Level of Evidence 4