Jaya Sai Chavali

When Partial Nephrectomy is Unsuccessful: Understanding the Reasons for Conversion from Robotic Partial to Radical Nephrectomy at a Tertiary Referral Center

Purpose: We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event. Materials and Methods: Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion. Results: The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p <0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p <0.01) and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar location) score (9 vs 8, p <0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96–0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22–1.7, p <0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short‐term oncologic outcomes but better renal functional preservation (p <0.01). Conclusions: At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion.

Current status of robotic single-port surgery

Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.

Perinephric and Sinus Fat Invasion in Stage pT3a Tumors Managed by Partial Nephrectomy

Micro‐Abstract From an anatomic perspective, stage pT3a tumors with sinus fat invasion (SFI) after partial nephrectomy could be considered more likely to develop recurrence than tumors with perinephric fat invasion (PFI). We included 85 patients with pT3a SFI and 58 patients with pT3a PFI in the present retrospective study. We compared the clinicopathologic characteristics, perioperative morbidity, and oncologic outcomes between the SFI and PFI groups. Progression‐free survival and overall survival analyses were performed. Survival curves were compared using the log‐rank test. SFI compared with PFI was not associated with an increased risk of progression or cancer‐specific death. Introduction We evaluated the influence of perinephric fat invasion (PFI) compared with sinus fat invasion (SFI) on disease‐free survival (DFS) and cancer‐specific survival (CSS) after partial nephrectomy (PN) for stage pT3a renal cell carcinoma (RCC). Materials and Methods Data were recorded from the consecutive records of patients who had undergone underwent PN for cT1‐T2 RCC from 2007 to 2016. Of these patients, 143 had stage pT3a with SFI or PFI found on final pathologic examination. The demographic, perioperative, and pathologic variables were reviewed. DFS and CSS analyses were performed. The factors predicting disease progression in this population were assessed. Results After a median follow‐up period of 28 months (range 15‐41 months), 19 patients (13.3%) had developed recurrence, including 5 local and 14 distant metastases, with 11 cancer‐specific deaths (7.7%). No differences were found in DFS (5 years, 60.9% vs. 55.3%; log‐rank P = .7) or CSS (5 years, 81% vs. 74.2%; log‐rank P = .8) between the SFI and PFI groups. For the pT3a fat invasion population, the 2‐ and 5‐year DFS and CSS rates were 83.6% and 58.6% and 93.6% and 78%, respectively. SFI (P = .5) and positive surgical margins (P = .1) did not predict for progression. On multivariate Cox regression, increased tumor size (hazard ratio, 1.5; 95% confidence interval, 1.1‐1.9; P < .01) and higher tumor grade (hazard ratio, 3.6; 95% confidence interval, 1.1‐4.6; P = .04) were independent predictors of disease progression in the pT3a fat invasion population. Conclusion In our series of patients with pT3a RCC after PN, SFI compared with PFI was not associated with an increased risk of progression or cancer‐specific death.

Imaging strategy and outcome following partial nephrectomy

OBJECTIVES The aim of this study was to analyze the outcomes of surveillance after partial nephrectomy (PN) in a single institution and the relevance of imaging studies in detecting recurrence. MATERIAL AND METHODS Retrospective study of 830 patients who underwent PN for localized renal cell carcinoma between 2007 and 2015 at a single institution. We studied the characteristics of recurrence according to pathological and clinical features and elaborated risk groups. The type and the total number of imaging studies performed during surveillance or until recurrence were evaluated. Outcomes of surveillance were analyzed. RESULTS There were 48 patients (5.8%) diagnosed with recurrence during median 36 [21-52] months follow-up, including local recurrence in 18 patients (37.5%) and metastasis in 30 patients (62.5%). Totally, 17/18 patients (94.4%) with local recurrence and 26/30 patients (86.6%) with metastasis were diagnosed within the first 36 months after PN. When studying the recurrence rate, and time-to-recurrence, 2 risk groups emerged. Patients with pathological characteristics (tumors with pT1b or higher or high-grade tumor or positive surgical margin status) or patients with anatomical characteristics (high or moderate R.E.N.A.L. score) or both had high recurrence rate. Chest x-ray and abdominal ultrasound detected 7.7% and 3.4% of all recurrences, respectively, whereas computed tomography scan and magnetic resonance imaging scan detected the rest. Of the 48 patients diagnosed with recurrence, 44 (91.6%) were suitable for secondary active treatment (systemic, surgery, and radiotherapy) including 26 (54.2%) suitable for metastasectomy. The rate of relapse after secondary treatment was 43.5% (16.6% for the local recurrence group and 60.7% for metastasis group). CONCLUSION Local recurrence emerges earlier than distant metastasis. Patients with any adverse pathological or anatomical features should be considered as high-risk group and followed closely in the first 36 months after PN with cross-sectional studies. Secondary active treatment is suitable for most patients, while surgical treatment fits fewer patients. Local recurrence is associated with increased rates of metastatic progression.

Kidney Cancer: Localized: Surgical Therapy IIMP49-06 WHEN PARTIAL NEPHRECTOMY IS UNSUCCESSFUL: UNDERSTANDING THE REASONS FOR CONVERSION FROM ROBOTIC PARTIAL TO RADICAL NEPHRECTOMY AT A TERTIARY REFERRAL CENTER

INTRODUCTION AND OBJECTIVES: To preserve renal function, partial nephrectomy is recommended to patients with small renal masses. However, controversy still exists as to whether prolonged ischemic time adversely affects the incidence of chronic kidney disease. We assessed the effect of prolonged ischemic time to global renal function following partial nephrectomy. METHODS: We reviewed data from 1,588 patients who underwent open or robotic partial nephrectomy for clinical T1 renal tumor with normal renal function (estimated glomerular filtration rate [eGFR] 60 mL/min/1.732). Patients were subjected to group A (ischemic time 30 minutes) or group B (ischemic time > 30 minutes). Propensity score matching was used to adjust for potential confounders, which resulted in 320 patients in each group. Postoperative renal function was evaluated at the last follow-up visit. Multivariate analysis was used to determine predictors for the newly acquired CKD (eGFR < 60 mL/min/1.732). RESULTS: In the groups A and B, mean ischemic time was 19.8 and 40.2 minutes respectively. There were no statistically significant differences in other baseline variables between the groups. After a median follow-up of 37 months, mean postoperative eGFR was similar (84.5 vs. 83.2 mL/min/1.732, p 1⁄4 0.424) and the rate of CKD did not differ in the two groups (6.3% vs. 7.2%, p 1⁄4 0.636). Prolonged ischemic time did not affect the newly acquired CKD among the open partial nephrectomy subgroup (p 1⁄4 0.847) and those with robotic partial nephrectomy (p 1⁄4 0.160). Moreover, dividing ischemic time into five groups ( 20, 21-30, 31-40, 41-50, and 50 minutes) provided no further information on new onset CKD (7.5%, 4.8%, 7.0%, 7.9%, and 6.5%, p 1⁄4 0.865) compared with the two groups with a cut-off at 30 minutes. CONCLUSIONS: In patients with a normal baseline renal function, prolonged ischemic time is not an independent predictor of CKD following partial nephrectomy.

MP22-01 PERIOPERATIVE MORBIDITY, ONCOLOGICAL OUTCOMES AND PREDICTORS OF PT3A UPSTAGING FOR PATIENTS UNDERGOING PARTIAL NEPHRECTOMY FOR CT1 TUMORS

INTRODUCTION AND OBJECTIVES: The question of whether upstaged and nonupstaged tumors have different outcomes continue to be discussed in the literature. Few published studies address this question, with a wide range of results. The aim of this study was to evaluate perioperative morbidity, oncological outcome and predictors of pT3a upstaging after partial nephrectomy(PN). METHODS: Retrospective study of 1042 patients who underwent PN for cT1 renal cell carcinoma between 2007 and 2015. A total of 113 cT1 patients were upstaged to pT3a, while 929 were staged pT1. Demographic, perioperative and pathological variables were reviewed. We compared the clinico-pathological characteristics, perioperative morbidity and oncological outcomes between pT3a and pT1 groups. Multivariate regression evaluates variables associated with T3a upstaging. Progression-free survival (PFS) and overall survival analyses were performed. RESULTS: pT3a tumors had a higher R.E.N.A.L score, higher hilar location, higher grade, and higher positive surgical margins. Patients with pT3a had a higher estimated blood loss, transfusion rate, ischemia time, overall complications, while there were no difference in median e-GFR decline and major (Grade III-V) complications. Five-year PFS was 78.5% for pT3a group, vs 94.6% for pT1 group (Log rank p <0.01). Male gender (OR 2.2, p<0.01), and R.E.N.A.L score (OR 2.3, p1⁄40.01) were preoperative predictors of upstaging. CONCLUSIONS: Perioperative morbidity is acceptable in pT3 tumors, however upstaged patients had a worse oncological outcomes. cT1/pT3a tumors are associated with adverse clinico-pathological features. Preoperative risk predictors of upstaging were, higher R.E.N.A.L score and male gender.

MP73-19 PREOPERATIVE PROTEINURIA PREDICTS INCREASED RATES OF ACUTE KIDNEY INJURY AFTER PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: The current evaluation of nephrectomy specimens centers on the pathological diagnosis, grade, and stage of the neoplasm.The evaluation of the non-neoplastic renal parenchyma is often overlooked. The remnant renal parenchyma can suffer the long-term effects of comorbidities, compromising functional outcomes. These changes can be assessed by histopathological analysis of non-neoplastic tissue of the nephrectomy specimen and can be used to predict the extent of future renal function compromise. In this study, we aim to evaluate changes in the non-neoplastic renal parenchyma in patients who were submitted to radical nephrectomy, as well as demographic and clinical parameters as predictors of decrease in renal function and development of new-onset CKD after surgery. METHODS: Data were extracted from 222 patients who underwent radical nephrectomy. The MDRD formula was used. The study end point was development of CKD, defined as an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m2. A renal pathologist assessed three histologic features in the non-neoplastic parenchyma, namely global glomerulosclerosis (GS), arteriosclerosis (AS), and interstitial fibrosis (IF). For GS assessment, the percent of affected glomeruli was determined. AS was graded and divided into three groups, namely 1d0%-25%, 2d26%-50%, and 3dgreater than 50%. IF was evaluated as absent or present.A nomogram was created to predict CKD following radical nephrectomy. RESULTS: After a mean follow-up of 49.06 months, the mean eGFR rate decrease was 26.5% after radical nephrectomy. Almost half of the patients (53.8%) developed CKD. For each 2.5% increase in GS, each point increase in Charlson comorbidity index, and each 10year increase in patient’s age, the eGFR decreased 28%, 33%, and 39%, respectively. In a univariate analysis, age, CCI, GS, AS, IF, hypertension, and DM were associated with new-onset CKD after radical nephrectomy. After multivariate logistic regression, CCI, GS, and baseline eGFR were associated with new-onset CKD after radical nephrectomy. CONCLUSIONS: Histopathological evaluation of nonneoplastic renal parenchyma in patients who undergo radical nephrectomy can be used to predict the development of new-onset CKD.

MP64-19 FACTORS PREDICTING PERSISTENTLY ELEVATED PROSTATE-SPECIFIC ANTIGEN AFTER RADICAL PROSTATECTOMY: RESULTS FROM A HIGH-VOLUME SINGLE INSTITUTION OVER 10 YEARS

INTRODUCTION AND OBJECTIVES: Persistently elevated prostate-specific antigen (PSA) after radical prostatectomy (RP) is associated with recurrent disease and poor prognosis. Predictors that may be associated with persistent PSA need to be evaluated in order to better counsel patients and gauge postoperative outcomes. We sought to assess independent clinical and pathologic predictors of persistently elevated PSA after RP in a contemporary cohort. METHODS: We identified a cohort of patients with non-metastatic prostate cancer who underwent RP from 2006-2016 at the Cleveland Clinic Foundation. Independent predictors of persistently elevated PSA were identified using chi-square and multivariate logistic regression analyses, accounting for patient demographic and clinicopathologic factors. Persistently elevated PSA was defined as 0.1 six weeks after RP. RESULTS: Of a total 2,710 patients undergoing RP, 158 patients had persistently elevated PSA after surgery (5.8%). On multivariate analysis, clinicopathologic factors associated with persistently elevated PSA included initial PSA >20 ng/mL (OR 2.8; p<0.01), extraprostatic extension (OR 3.3; p<0.01), seminal vesicle invasion (OR 1.6; p1⁄40.048), positive surgical margin (OR 2.0; p<0.01), lymph node involvement (OR 2.5; p<0.01), and pathologic Gleason score 8 (OR 4.5; p<0.01). CONCLUSIONS: With persistently elevated PSA after RP recognized as a marker of continued disease progression, clinicopathologic factors that predicted persistently elevated PSA were characterized in a contemporary cohort. These results highlight factors that can assist with determination of necessity for adjuvant therapy and help with better patient counseling prior to and following prostatectomy.

MP67-09 SURVEILLANCE STRATEGY AND OUTCOME AFTER PARTIAL NEPHRECTOMY

Eu Chang Hwang*, Yang Hyun Cho, Ho Seok Chung, Seung Il Jung, Taek Won Kang, Dong Deuk Kwon, Gwangju, Korea, Republic of; Myung Ki Kim, Jeonju, Korea, Republic of; Sung Gu Kang, Seok Ho Kang, Jun Cheon, Seoul, Korea, Republic of; Ja Yoon Ku, Hong Koo Ha, Busan, Korea, Republic of; Chang Wook Jeong, Ja Hyeon Ku, Cheol Kwak, Seoul, Korea, Republic of; Tae Gyun Kwon, Tae-Hwan Kim, Seock Hwan Choi, Daegu, Korea, Republic of; Ill Young Seo, Iksan, Korea, Republic of