Rebecca L. O'Malley

Changes in Renal Function Following Nephroureterectomy May Affect the Use of Perioperative Chemotherapy

BACKGROUND Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function. OBJECTIVE Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function. DESIGN, SETTINGS, AND PARTICIPANTS We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included. INTERVENTION All patients underwent nephroureterectomy. MEASUREMENTS All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2-52 wk). Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease study equation. eGFR values before and after surgery were compared using the paired t test. We chose an eGFR of 45 and 60 ml/min per 1.73 m(2) as possible cut-offs for chemotherapy eligibility and compared eligibility before and after surgery using the chi-square test. RESULTS AND LIMITATIONS Our cohort of 388 patients included 233 men (60%) with a median age of 70 yr. Mean eGFR decreased by 24% after surgery. Using a cut-off of 60 ml/min per 1.73 m(2), 49% of patients were eligible for chemotherapy before surgery, but only 19% of patients remained eligible postoperatively. Using a cut-off of 45 ml/min per 1.73 m(2), 80% of patients were eligible preoperatively, but only 55% remained eligible after surgery. This distribution persisted when we limited the analysis to patients with advanced pathologic stage (T3 or higher). Patients older than the median age of 70 yr were more likely to be ineligible for chemotherapy both pre- and postoperatively by either definition, and they were significantly more likely to have an eGFR <45 ml/min per 1.73 m(2) postoperatively, regardless of their starting eGFR. This study is limited by its retrospective nature, and there was some variability in the timing of postoperative serum creatinine measurements. CONCLUSIONS eGFR is significantly diminished after nephroureterectomy, particularly in elderly patients. These changes in renal function likely affect eligibility for adjuvant cisplatin-based therapy. Accordingly, we suggest strong consideration of neoadjuvant regimens.

Effect of Warm Ischemia Time During Laparoscopic Partial Nephrectomy on Early Postoperative Glomerular Filtration Rate

PURPOSE We evaluated the effect of warm ischemia time on early postoperative renal function following laparoscopic partial nephrectomy. MATERIALS AND METHODS Of 453 patients who were surgically treated for renal tumors between May 2001 and September 2007, and who were identified in our database 128 underwent laparoscopic partial nephrectomy. Of these 128 patients 101 who were evaluable had complete demographic, operative, preoperative and early postoperative data available. Renal function was estimated using the glomerular filtration rate. Warm ischemia time was stratified into 4 interval groups and also analyzed based on different time cutoffs. Ultimately we also tested the relationship between postoperative renal failure, and preoperative factors and warm ischemia time. RESULTS Warm ischemia time interval analysis was not significant. However, when analyzing the effect of warm ischemia time cutoffs, patients with warm ischemia time greater than 40 minutes had a significantly greater decrease in the glomerular filtration rate (p = 0.03) and a lower glomerular filtration rate postoperatively. The incidence of renal function impairment was more than 2-fold higher in those with a warm ischemia time of greater than 40 minutes than in the other groups (p = 0.077). Warm ischemia time was significant on univariate analysis when only patients with a preoperative glomerular filtration rate of 60 ml per minute per 1.73 m(2) or greater were analyzed. However, this did not hold as an independent predictor of postoperative renal function impairment on multivariate analysis. The preoperative glomerular filtration rate was the only independent predictor of postoperative renal function impairment. CONCLUSIONS A warm ischemia time of 40 minutes appears to be an appropriate cutoff, after which a significantly greater decrease in renal function occurs after laparoscopic partial nephrectomy. The preoperative glomerular filtration rate was the only independent predictor of an increased risk of renal insufficiency following laparoscopic partial nephrectomy.

Bosniak Category IIF Designation and Surgery for Complex Renal Cysts

PURPOSE We investigated whether adding the IIF categorization improved the accuracy of Bosniak renal cyst classification, as evidenced by a low rate of progression in IIF lesions and a high rate of malignancy in category III lesions. MATERIALS AND METHODS We retrospectively reviewed the records of patients with complex renal cysts categorized as a Bosniak IIF or III. Surveillance imaging and pathological outcomes of category IIF cysts were recorded to determine radiological predictors of progression. Pathological outcomes of category III cysts were recorded to determine the malignancy rate. RESULTS A total of 112 patients met study inclusion criteria, of whom 81 were initially diagnosed with a category IIF cyst and 31 had a Bosniak category III cyst. At a median followup of 15 months 14.8% of Bosniak IIF lesions progressed in complexity with a median time to progression of 11 months (maximum greater than 4 years). There were no differences in tumor or patient characteristics between cysts that progressed and those that remained stable. In the 33 patients with Bosniak III lesions who underwent surgical extirpation the malignancy rate was 81.8%. Most patients had low stage, low grade disease and remained recurrence-free at a median followup of 6 months. CONCLUSIONS Adding the IIF category has increased the accuracy and clinical impact of the Bosniak categorization system, as evidenced by a low rate of progression in category IIF cysts and an increased rate of malignancy in surgically treated category III lesions compared to those in historical controls.

The Necessity of Adrenalectomy at the Time of Radical Nephrectomy: A Systematic Review

PURPOSE We describe the literature base pertaining to adrenalectomy at radical nephrectomy and present a pragmatic approach based on primary tumor and disease characteristics. MATERIALS AND METHODS Literature searches were performed via the National Center for Biotechnology Information databases using various keywords. Articles that pertained to the concomitant use of adrenalectomy with radical nephrectomy were surveyed. RESULTS The incidence of solitary, synchronous, ipsilateral adrenal involvement, ie that which is potentially curable with ipsilateral adrenalectomy along with nephrectomy, is much lower than previously thought at 1% to 5%. Evidence to date supports increased size and T stage, multifocality, upper pole location and venous thrombosis as risk factors for adrenal involvement. Cross-sectional imaging is now accurate at demonstrating the absence of adrenal involvement but still carries a significant risk of false-positives. The morbidity of adrenalectomy is minimal except in those patients with metachronous contralateral adrenal metastasis in whom the impact of adrenal insufficiency can be devastating. Disease specific and overall survival of those undergoing radical nephrectomy, with or without adrenalectomy, are similar. The survival of patients with widespread metastatic disease is historically poor regardless of whether adrenalectomy is performed. There is evidence for a survival advantage in patients with isolated adrenal metastasis, although this group comprises no more than 2% of those undergoing surgery for renal tumors. CONCLUSIONS The apparent benefit of ipsilateral adrenalectomy does not support it as a standard practice in all patients with normal imaging. However, it should be considered in select cases in which there are risk factors for adrenal involvement.

A matched‐cohort comparison of laparoscopic cryoablation and laparoscopic partial nephrectomy for treating renal masses

To compare the surgical outcomes of elderly patients with renal masses treated with laparoscopic partial nephrectomy (LPN) or laparoscopic cryoablation (LCA).

Lymph node dissection during the surgical treatment of renal cancer in the modern era

The increasing use of routine CT scan, along with advances in imaging technology, have facilitated the early diagnosis of incidental renal masses. This has resulted in the reduction in the rate of metastatic disease diagnosis. Although surgery remains the mainstay in the treatment of renal tumors, the decreasing incidence of lymph node involvement has created controversy regarding the importance and the ideal extent of lymph node dissection, formerly considered mandatory at the time of radical nephrectomy. In this review, we critically assessed the role of lymph node dissection at the time of radical nephrectomy. To date, randomized trials have failed to show a benefit of lymph node dissection when broadly employed. This is likely due to the low prevalence of lymph node metastasis at the time of presentation, the unpredictable pattern of lymph node metastasis from renal tumors, and the continued downward stage migration of the disease. As a result, lymph node dissection for renal cancer is currently not recommended in the absence of gross lymphadenopathy. In high risk patients, lymph node dissection may be considered, but it remains controversial and more clinical evidence is warranted. Extended lymph node dissection is still recommended in individuals with isolated gross nodal disease or those with lymphadenopathy at the time of cytoreductive surgery prior to systemic therapy. A practical approach is summarized in an algorithm form.

Re: Changes in Renal Function Following Nephroureterectomy may Affect the Use of Perioperative Chemotherapy

Background—Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function. Objective—Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function. Design, settings, and participants—We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included. Intervention—All patients underwent nephroureterectomy. Measurements—All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2[en]52 wk).

Para-anastomotic haematoma volume predicts the presence of anastomotic extravasation after radical retropubic prostatectomy

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

Population-based analysis of cancer control of partial nephrectomy for high-risk localized renal cell carcinoma.

385 Background: Partial nephrectomy (PN) has reported equivalent oncologic outcomes with superior renal function outcomes when compared to radical nephrectomy (RN) for treatment of localized renal cell carcinoma (RCC). Whether PN provides adequate cancer control in high risk disease is unclear. To clarify, survival outcomes were compared between those who underwent RN and PN for high risk RCC. METHODS Using the Surveillance, Epidemiology, and End Results database patients with RCC who underwent PN or RN for a localized tumor ≤ 7cm were identified. Cancer-specific (CSS) and overall survival (OS) were compared between those with high risk disease (defined as poorly or undifferentiated grade and/or pathologic stage T3) who underwent PN or RN. RESULTS Of 51,183 patients with localized RCC ≤ 7cm, 24.9% had high risk disease, 85.2% and 14.8% of which underwent RN and PN, respectively. Five-year CSS was superior in the PN group vs. the RN group (93.3% vs. 86.0%, p<0.001). On multivariable analysis undergoing RN was no longer predictive of CSS (HR 1.23, p=0.08). Similarly, 5-year OS was superior in the PN versus RN group (79.5% vs. 70.1%, p<0.001). RN remained independently associated with poor OS on multivariable analysis (HR 1.16, p=0.031). Propensity analysis accounting for factors affecting selection for type of nephrectomy produced similar results. RN did not influence CSS but portended a 20% increased risk of death from all causes (p=0.008). CONCLUSIONS In patients with high risk RCC, partial nephrectomy is associated with improved OS and does not compromise cancer control as compared to radical nephrectomy.

DO DISPARITIES IN UTILIZATION OF PARTIAL NEPHRECTOMY OCCUR AT A TERTIARY REFERRAL CENTER

INTRODUCTION AND OBJECTIVE: Few population-based studies have assessed variations in the burden of erectile dysfunction (ED) by race/ethnicity. The purpose of this analysis is to estimate prevalence rates of ED by race/ethnicity and determine the contribution of behavioral risk factors, chronic illnesses, and socioeconomic factors to potential race/ethnic differences in ED. METHODS: The Boston Area Community Health (BACH) Survey is a study of urologic symptoms in a racially and ethnically diverse population. BACH used a multistage stratified random sample to recruit 2301 men age 30-79 years from the city of Boston. ED was assessed using the validated 5-item International Index of Erectile Function. Selfreported race/ethnicity was defined as Black, Hispanic, and White. Socioeconomic status (SES) was defined as a combination of education and household income. RESULTS: Overall prevalence of ED was 20.7% with higher prevalence observed among both Black men (24.9%) and Hispanic men (25.3%) compared to White men (18.1%). Increased odds of ED were observed for both Black and Hispanic men after adjusting for age, comorbid conditions (cardiovascular disease, diabetes, depression), and behavioral risk factors (smoking, physical activity, alcohol use). After controlling for the effect of SES, the association between race/ethnicity and ED disappeared. In contrast, men in the low SES category had an over two-fold increase in risk of ED (adjusted OR of 2.52, 95%CI: 1.63, 2.91). CONCLUSIONS: Findings from this study demonstrate that, after appropriate statistical control, SES accounts for differences in ED prevalence previously attributed to race/ethnicity.