Katherine A. Brewer

Impact of Cytoreductive Nephrectomy on Eligibility for Systemic Treatment and Effects on Survival: Are Surgical Complications or Disease Related Factors Responsible?

OBJECTIVE To understand the impact of cytoreductive nephrectomy on the ability to receive systemic therapy in patients with metastatic renal cell carcinoma. Causes of delayed eligibility and effect on overall survival (OS) were investigated. METHODS Patients with metastatic renal cell carcinoma who underwent cytoreductive nephrectomy between 2002 and 2010 were identified. Those ineligible to receive systemic therapy>2 months after surgery were considered delayed. Reasons for delay and effect on OS were investigated, including a thorough analysis of surgical morbidity. RESULTS Of 65 patients identified, 28% experienced delayed eligibility for systemic therapy. Reasons for delay were related to surgery in 33%, disease progression in 56%, and both in 11%. Of the entire cohort, pT4 and sarcomatoid disease predicted poor outcomes with median OS of 9.8 and 7.6 months, respectively. Comparison of the delay vs no delay groups revealed more intraoperative complications (P=.01), a trend toward more high-grade postoperative complications (17% vs 4%, P=.09), and a median OS of 4.8 vs 18.9 months. Controlling for grade and stage, delay and sarcomatoid features independently predicted poor OS (HR, 2.61; P=.01 and HR, 2.25; P=.02, respectively). CONCLUSION Delay in eligibility for systemic therapy after cytoreductive nephrectomy adversely affects OS and is most commonly caused by disease-related factors, although high-grade complications may contribute. Those with evidence of T4 or sarcomatoid disease features may best be served by systemic therapy followed by cytoreductive nephrectomy only in those exhibiting response.

Perioperative and renal function outcomes of minimally invasive partial nephrectomy for T1b and T2a kidney tumors.

PURPOSE To compare operative and functional outcomes of minimally invasive partial nephrectomy (MPN) and minimally invasive radical nephrectomy (MRN) for T(1b) and T(2a) renal tumors. PATIENTS AND METHODS All patients who underwent MPN or MRN for a localized, solitary renal mass 4 to 10 cm were included. Perioperative and renal function outcomes were compared. Propensity analysis was used to account for selection bias in type of nephrectomy when evaluating complication rates. RESULTS One hundred and eight patients underwent MRN and 45 underwent MPN between August 2004 and September 2010. Preoperative patient and tumor characteristics were similar between groups. Tumor size was larger in the MRN group (5.3 vs 6.8 cm, P<0.001). Operative times and positive margin rates were similar between the groups (P=0.956 and P=0.207, respectively). Estimated blood loss was higher in the MPN group (401.8 vs 157.1 mL, P<0.001), but transfusion rates were similar (P=0.225). Rates of intraoperative (P=0.724), postoperative (P=0.806), and high Clavien-grade postoperative complications (P=0.966) were similar. Propensity analysis indicated that the likelihood of any complication (odds ratio [OR] 0.810, confidence interval [CI] 0.331-1.982, P=0.645) or of a high-grade complication (OR 0.164, CI 0.011-2.513, P=0.194) was unrelated to type of nephrectomy. With similar preoperative renal function parameters, postoperative development of new stage III to V chronic kidney disease (CKD) was greater in the MRN group (58 vs 31%, P=0.011). Propensity analysis showed that the likelihood of new CKD was 2.8 times higher in the MRN group (P=0.048). CONCLUSION In selected patients and with appropriate surgical expertise, MPN can result in similar rates of complications but superior renal function outcomes in larger kidney tumors.

771 A COMPARISON OF PERI-OPERATIVE OUTCOMES OF ROBOT-ASSISTED AND PURE LAPAROSCOPIC PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: Compared to open prostatectomy, both pure laparoscopic radical prostatectomy (LRP) and robot assisted laparoscopic prostatectomy (RALP) remarkably reduce the postoperation pain. However, differences between LRP and RALP techniques in terms of postoperative pain have not been yet explored. METHODS: A total of 100 patients requiring prostatectomy were randomized in 2 groups. One group was treated with LRP technique (LRPg), while the other group was treated with RALP (RALPg). In both groups intraoperative anesthesia and postoperative analgesia were managed according to the same protocols. The degrees of postoperative pain were evaluated on each patient by the Visual Analogue Scale diffused (VAS D), incident (the pain on light compression of surgical wound) (VAS I) and “referred” (the shoulder-pain) (VAS R) pain scores. The 3 VAS pain scores, the consumption of analgesic opiods (buprenorphine), and the amount of rescue drugs (acetaminophen) at 1, 3, 6 and 24 h after surgery in the 2 groups were compared respectively. RESULTS: Althought both group have low VAS D and VAS I, RALPg has lower VAS than LRPg. Change in post operative pain VAS I (Fig 1) and VAS D (Fig 2). VAS 0 no pain, VAS 10 maximum pain. Measurements were recorded at 1, 3, 6, 24 h after operation. Vertical bars denote 0.95 confidence intervals. Otherwise VAS R in all the evaluation, at 1, 3, 6 and 24 h after surgery, were not statistically significative. Compared to the LRPg, the RALPg required less analgesic opioids (345 53 mg vs. 451 103 mg, p 0.001). The cases requiring rescue drugs were lower in RALP group than in LRPg both at 24 h (24.32% versus 46,87%, p 0.05), and at 48 h after surgery (12.12% versus 18.51%, p 0.05). CONCLUSIONS: Our study suggests that RALP causes less postoperative pain than LRP with lower required of analgesic drugs in post operative period. Further studies are required to confirm and explain these data. Source of Funding: None