Onder Kara

Five-year Oncologic Outcomes After Transperitoneal Robotic Partial Nephrectomy for Renal Cell Carcinoma

BACKGROUND Robotic partial nephrectomy (RPN) is established as a minimally invasive nephron-sparing technique with excellent perioperative and intermediate oncologic outcomes. However, long-term oncologic outcomes have not been reported to date. OBJECTIVE To report long-term oncologic outcomes of RPN. DESIGN, SETTING, AND PARTICIPANTS Consecutive patients undergoing RPN from June 2006 to March 2010 were selected from our prospective RPN database. Patients with benign tumors, prior ipsilateral PN, or prior radical nephrectomy and those with follow-up of <1 mo were excluded. INTERVENTION Transperitoneal RPN. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS Demographic, perioperative, and postoperative data were analyzed. Overall survival (OS), cancer-free survival (CFS), and cancer-specific survival (CSS) were evaluated using Kaplan-Meier survival analysis. Univariate logistic regression analysis for overall mortality was performed to evaluate the odds ratio (OR) for variables of interest. RESULTS AND LIMITATIONS In total, 115 RPNs for RCC were performed in 110 patients. The mean age was 59.8±11.0 yr and the median age-adjusted Charlson comorbidity index (ACCI) was 4 (interquartile range [IQR] 3-5). The median tumor size was 2.6cm (IQR 2.0-3.7) and median RENAL score was 7 (IQR 6-9). Clear cell carcinoma was present in 67.8% of cases, and two cases (1.7%) had positive surgical margins. Glomerular filtration rate preservation was 87.8% (IQR 74.9-98.1), which translates to 19.1% chronic kidney disease upstaging. The median follow-up was 61.9 mo (IQR 50.9-71.4) and the 5-yr OS, CFS, and CSS were 91.1%, 97.8%, and 97.8%, respectively. On univariable logistic regression, ACCI was the only factor associated with a higher risk of overall mortality (OR 1.67, p=0.006). The retrospective design, the high surgical volume at our institution, and the potential selection bias with careful patient selection early in the RPN experience may limit the generalizability of our findings. CONCLUSIONS This is the first study confirming excellent long-term oncologic outcomes after RPN in a selected cohort of patients. PATIENT SUMMARY Robotic partial nephrectomy is a relatively recently developed treatment for renal cell carcinoma. This study confirms its safety and reports excellent long-term cancer control.

Predictors of Excisional Volume Loss in Partial Nephrectomy: Is There Still Room for Improvement?

UNLABELLED Since volume loss is the most important modifiable determinant of long-term renal function after partial nephrectomy, there is great interest in ways to reduce the loss of healthy parenchyma. We retrospectively reviewed 880 partial nephrectomies to identify predictors of excisional volume loss (EVL), based on pathologic assessment. After stepwise variable selection, we assessed age, sex, solitary kidney status, tumor size, endophytic property, estimated blood loss, surgical approach, and surgeon volume for association with EVL using multiple regression. Male sex (p<0.01), larger tumors (p<0.01), endophytic tumors (p=0.01), open approach (p<0.01), increased bleeding (p<0.01), and higher surgeon volume (p<0.01) were independently associated with greater EVL. Approach strongly influenced EVL with open surgery having 7.8 cm(3) more EVL than robotic surgery. Negative surgical margins (95.7% vs 94.1%, p=0.32) did not differ between open and robotic approaches, respectively. EVL is associated with patient, tumor, and especially provider factors, suggesting that volume preservation may be improved with surgical optimization. Lack of percent volume loss data, which precluded assessment of EVLs impact on long-term renal function, is a limitation. PATIENT SUMMARY We found that surgical approach affects the quantity of healthy kidney removed during cancer surgery, suggesting that there is room for further surgical improvement.

Excisional Precision Matters: Understanding the Influence of Excisional Volume Loss on Renal Function After Partial Nephrectomy

Renal function after partial nephrectomy (PN) may depend on modifiable factors including ischemia time, excision of healthy parenchyma (excisional volume loss, EVL), and reconstructive methods. We retrospectively reviewed our institutional robotic PN database to identify the predictors of glomerular filtration rate (GFR) preservation (GFR-P) at 3-12 mo postoperatively, during which GFR decline plateaus. Baseline clinical, sociodemographic, and radiologic characteristics were captured. Univariate and multivariate (MV) linear regression analyses were performed and marginal effects were employed to examine the relative effect of EVL on renal function. A total of 647 patients who underwent robotic PN had GFR data at a median follow-up of 6 mo. On MV models, EVL was significantly correlated with GFR-P following log transformation (p=0.001). Each doubling of EVL caused a 1.5% decrease in GFR-P. Ischemia time and tumor complexity were not significantly associated with GFR-P. In summary, GFR-P after PN appears to be significantly associated with the excised volume of benign parenchyma. PATIENT SUMMARY At a high-volume tertiary care center, we investigated the impact of surgical factors on kidney function after kidney cancer surgery. We found that the surgical precision with which the tumor is excised significantly impacts kidney function at 3-12 mo after surgery.

PCA3-based nomogram for predicting prostate cancer and high grade cancer on initial transrectal guided biopsy

To develop a validated prostate cancer antigen 3 (PCA3) based nomogram that predicts likelihood of overall prostate cancer (PCa) and intermediate/high grade prostate cancer (HGPCa) in men pursuing initial transrectal prostate biopsy (TRUS‐PBx).

Comparison of robot-assisted and open partial nephrectomy for completely endophytic renal tumours: a single centre experience.

To compare outcomes between robot‐assisted partial nephrectomy (RAPN) and open PN (OPN) for completely endophytic renal tumours.

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.

Perioperative morbidity, oncological outcomes and predictors of pT3a upstaging for patients undergoing partial nephrectomy for cT1 tumors

ObjectivesTo evaluate perioperative morbidity, oncological outcome and predictors of pT3a upstaging after partial nephrectomy (PN).Materials and methodsRetrospective study of 1042 patients who underwent PN for cT1N0M0 renal cell carcinoma between 2007 and 2015. A total of 113 cT1 patients were upstaged to pT3a, while 929 were staged as 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. Recurrence-free survival (RFS) and overall survival analyses were performed. Survival curves were compared using log-rank test.ResultsThe pT3a tumors were high complexity tumors (median RENAL score 8 vs. 7, p < 0.01), higher hilar (h) location (27.5 vs. 14.8%, p < 0.01), higher grade (57.5 vs. 38.2%, p < 0.01), and higher positive surgical margins (18.6 vs. 5.8%, p < 0.01. Patients with pT3a had a higher estimated blood loss, transfusion rate, ischemia time and overall complications, though there were no differences in median e-GFR decline and major (Grade III-V) complications. Five-year RFS 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, p = 0.01) were preoperative predictors of upstaging. We acknowledge limitations in our study, most are inherent problems of retrospective studies.ConclusionPerioperative morbidity, after partial nephrectomy, is acceptable in cT1/pT3 tumors in comparison to cT1/pT1; however, upstaged patients had a worse oncological outcome. 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.

Patterns and Predictors of Recurrence after Partial Nephrectomy for Kidney Tumors

Purpose: We sought to identify patterns and predictors of recurrence in patients with clinically localized renal cell carcinoma managed by partial nephrectomy. Materials and Methods: We performed a retrospective study of 830 consecutive cases of partial nephrectomy done between 2007 and 2015 for clinically localized renal cell carcinoma at a single institution. Patient demographics and pathological characteristics were correlated with recurrence patterns (overall, local and distant) and overall survival using Kaplan‐Meier and Cox regression analyses. Differences in the recurrence patterns were evaluated. Results: Median patient age was 61 years and median tumor size was 3.1 cm. Overall, 11.6% of tumors were stage pT3, 39.3% were high grade, 2.9% had lymphovascular invasion and 7.1% had positive margins. Higher grade, higher stage, positive surgical margins and increased R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line) score were associated with shorter disease‐free survival on Kaplan‐Meier analysis. On multivariable regression pT (p <0.01), grade (p <0.01) and R.E.N.A.L. score (p = 0.03) remained independent predictors of disease‐free survival. Predictors of metastasis were pT stage (HR 4.5) and grade (HR 3.9, both p <0.01), while R.E.N.A.L. score (HR 3.2, p = 0.03) was the single predictor of local recurrence. Five‐year disease‐free and overall survival probabilities were 91% and 94%, respectively. Local recurrence manifested and developed earlier than metastasis (median 13 vs 22 months, p <0.01). Conclusions: High pT stage, high grade and high R.E.N.A.L. score increase the risk of disease recurrence after partial nephrectomy. The pT stage and grade are predictors of metastasis, while R.E.N.A.L. score predicts local recurrence. Because relapse features and risk factors differ between the 2 recurrence patterns, they should be studied separately in the future.

Robot-assisted approach improves surgical outcomes in obese patients undergoing partial nephrectomy

To assess the impact of approach on surgical outcomes in otherwise healthy obese patients undergoing partial nephrectomy for small renal masses.

External validation of a PCA-3-based nomogram for predicting prostate cancer and high-grade cancer on initial prostate biopsy

The aim of this study was to externally validate a previously developed PCA3‐based nomogram for the prediction of prostate cancer (PCa) and high‐grade (intermediate and/or high‐grade) prostate cancer (HGPCa) at the time of initial prostate biopsy.