Sean Berquist

Statin utilization improves oncologic and survival outcomes in patients with dyslipidemia and surgically treated renal cell carcinoma

BACKGROUND We evaluated the role of statins in patients who underwent surgery for renal cell carcinoma (RCC) and who had dyslipidemia, as use of statins has been suggested to improve outcomes in RCC. METHODS Two-center retrospective study of patients with dyslipidemia who underwent surgery for RCC from 7/1995 to 6/2005. Patients were managed by statins or ezetimibe, fibrate agents, or cholestyramine. Analysis was conducted between patients who received statin therapy versus those that did not. Primary outcome was progression-free survival (PFS). Secondary outcomes were cancer-specific (CSS) and overall survival (OS). Multivariable analysis was performed to identify risk factors associated with disease progression. RESULTS In this study 283 patients were analyzed (180 statin, 103 non-statin, median follow-up 68 months). There were no significant demographic differences. Median duration of antidyslipidemia therapy was similar (statin 31 months vs. non-statin 28 months, P=0.413). Tumor size (statin 5.4 cm vs. non-statin 5.6 cm, P=0.569), stage distribution (P=0.591), histology (P=0.801), and grade (P=0.807) were similar. Kaplan-Meier analysis demonstrated higher 5-yr PFS (91% vs. 70%, P<0.001), CSS (88% vs. 69%, P<0.001), and OS (71% vs. 67%, P=0.025) in statin vs. non-statin patients. Multivariable analysis for factors associated with disease progression found absence of statin therapy (OR 2.41, P<0.001), higher stage (OR 2.01-3.86 P<0.001), and higher grade tumors (OR 2.07, P=0.006) to be predictive. CONCLUSIONS In RCC patients with dyslipidemia, statin use was associated with improved survival outcomes, and was an independent predictor of PFS. Further investigations are requisite to determine utility of statins in RCC patients.

Corrigendum to “Collision Tumor With Renal Cell Carcinoma and Plasmacytoma: Further Evidence of a Renal Cell and Plasma Cell Neoplasm Relationship?” [Urology Case Reports 6 (2017) 50–52]

[This corrects the article DOI: 10.1016/j.eucr.2016.03.005.].

PD20-07 ONCOLOGIC AND SURVIVAL OUTCOMES FOR PATHOLOGIC T3A UPSTAGING IN CLINICALLY LOCALIZED RENAL MASSES: DOES PARTIAL NEPHRECTOMY INCREASE ONCOLOGICAL RISK?

continuous and categorical variables, respectively. Outcomes of interest includedestimatedblood loss,warm ischemia time, estimatedglomerular filtration rate at 6 months, length of stay, margin status, Fuhrman grade, tumor size, pathological histology, and symptoms index at presentation RESULTS: Among our cohort, 376 (62%) and 228 (38%) patients with were scheduled for RN and PN, respectively. Of the 228 patients originally scheduled for PN, 12% were converted to RN intraoperatively. A smaller proportion of patients scheduled to undergo PN had clear cell/conventional histology (77% vs 88%; p1⁄40.001) on pathology compared to patients scheduled for RN. Among patients with clear cell or papillary histology, a larger proportion of patients scheduled for PN had lower Fuhrman grade (24% vs 10.3% had FG 1 or 2; p<0.0001) on pathology than patients scheduled for RN. Of our 604 patients, 111 patients died, 33 from kidney disease. The median follow up time for survivors was 2.0 years from surgery. On multivariable analysis, scheduled PN was non-significantly associated with better OS (HR 0.62; 95% C.I. 0.37, 1.03; p 1⁄4 0.064), better CSS (HR 0.51; 95% C.I. 0.18, 1.49; p 1⁄4 0.2), and better RFS (HR 0.56; 95% C.I. 0.29, 1.07; p1⁄40.081). From the estimates of the hazard ratio, we suspect that the bias related to surgeons choosing PN or RN based on low or high risk disease is not appropriately adjusted for in our model CONCLUSIONS: We found no evidence to suggest that PN has poorer outcomes than RN in patients with pT3a tumors. The inherent benefits of PN on renal function preservation make this approach very attractive even in larger and complex tumors

MP67-07 PATHOLOGICAL DETERMINANTS OF ONCOLOGIC OUTCOMES IN STAGE II RENAL CELL CARCINOMA: AN INTERNATIONAL MULTICENTER ANALYSIS

bilateral kidneys with single eAML on the left). Only one patient suffered from spontaneous haemorrhage. Two cases developed distant metastasis: one had nodules over bilateral lungs and left anterior mediastinum; the other had recurrence over liver and retroperitoneum one year after surgical intervention. Three cases had venous thrombus (two in renal vein and one in inferior vena cava) and received thrombectomy. All 21 cases received surgical intervention: 13 radical nephrectomy, 7 partial nephrectomy, one was found with retroperitoneal eAML arising from renal capsule thus undergone tumor excision without kidney involvement. The follow up period ranges from 1 to 143 months (average 51 months). Only 2 cases died from unrelated cause. CONCLUSIONS: In our study, the rate of aggressive behavior is 24% (2 distant metastasis and 3 venous invasion in the 21 cases). Some noticeable accompanying characteristics including haemorrhage, coexisting with AML, coexisting with renal cell carcinoma are also seen in this series. The incidence of renal vein and inferior vena cava thrombus formation in our series is high (3 out of 21), therefore, detailed preoperative image evaluation is necessary.

PD73-07 ANALYSIS OF RISK FACTORS ASSOCIATED WITH INFECTIONS COMPLICATIONS FOLLOWING PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: The duration of renal ischemia is the largest modifiable risk factor during partial nephrectomy. The shorter the warm ischemia time during LPN the lower the effect on long-term renal function. Real advantages of offclamping LPN compared with clamping surgery are not yet sufficiently studied. Few studies reported results of off-clamping LPN for high RENAL score cases. We compared Trifecta outcomes of the LPN with and without clamping stratifying cases through nephrometric RENAL score. METHODS: A total of 109 cases classified as low-complexity (54), intermediate-complexity (33) and high-complexity (22) underwent clamping (55) or off-clamping (54) laparoscopic partial nephrectomy and were compared in each group (clamping x off-clamping LPN). Clamping technique was performed with cold scissors intended to obtain 0.5cm of free surgical margins. Off-clamp technique was performed with harmonic scalpel close to the plane of enucleating to achieve minimal surgical margins. Renal function was measured at 1, 6 and 12 months postoperatively. All enrolled patients had normal contralateral kidney. Trifecta (Trifecta criteria: Clavien 2, negative-margins, and warm ischemia time 20 min) outcomes were analyzed and compared between the groups stratified by the nephrometric RENAL score. RESULTS: Trifecta achievement was similar in both groups for low complexity tumors (p < 0.31). The off-clamping group achieved higher trifecta rates for the intermediate (87.5% x 23.5%, p < 0.001) and high (83% x 0%, p < 0.005) complexity tumors. Patients with off-clamp technique had higher mean blood loss (150 X 400 ml) with no difference in blood transfusions. In the clamping group, significant higher proportion did not achieve trifecta (45.5% x 7.4%, p < 0.001). After 1 year, the difference of remnant renal function was 10% more for patients with off clamp surgery with high complexity RENAL score CONCLUSIONS: Off-clamping pure LPN was associated to accomplish higher trifecta rates for intermediate and high complexity RENAL score tumors. Long-term renal function was slightly better for off clamp group. It is unclear if off-clamp technique or differences in the amount resected of renal parenchyma were responsible for observed differences.

Comparison of laparoendoscopic single-site (LESS) and multiport laparoscopic radical nephrectomy for clinical T1b and T2a renal masses.

BACKGROUND The aim of this study was to compare outcomes of laparoendoscopic single-site surgery (LESS) and multiport laparoscopic (MPL) radical nephrectomy (RN) for clinical T1b/T2a renal masses, as concerns continue regarding suitability and benefit of LESS for larger renal masses. METHODS Retrospective single-surgeon comparison of LESS- and MPL-RN between 7/2005 and 11/2014. Sixty-three patients underwent LESS-RN (44 cT1b/19 cT2a); 133 underwent MPL (83 cT1b/50 cT2a). All patients were managed with a standardized care pathway. Primary outcome was length of hospital stay (LOS). Secondary outcomes included operative time, estimated blood loss (EBL), complications, discharge pain score (visual analog pain, VAP), narcotic requirement (morphine equivalents, MSO4eq). RESULTS 130/133 MPL and 62/63 LESS were successfully performed. For MPL and LESS groups: mean tumor diameter (cm) for cT1b was 5.3 vs. 5.4 (P=0.689); and for cT2a was 8.2 vs. 8.3 (P=0.728); mean OR time (min) was 126.3 vs. 132.7 (P=0.314); mean EBL (mL) was 139.5 vs.127.8 (P=0.49). No significant differences in complications were noted (P=0.781). LESS was associated with significant reductions in LOS (2.14 vs. 2.45 days, P=0.043), discharge VAP (1.3 vs. 2.2, P<0.001), and narcotic use (5.9 vs. 10.7 MSO4eq, P<0.001). CONCLUSIONS LESS is comparable to MPL-RN for cT1b and T2a renal tumors in terms of perioperative parameters and may confer benefit with respect to LOS and analgesic requirement.

Gastrointestinal tract access for urological natural orifice transluminal endoscopic surgery.

We conducted a literature review of natural orifice transluminal endoscopic surgery (NOTES), focusing on urologic procedures with gastrointestinal tract access, to update on the development of this novel surgical approach. As part of the methods, a comprehensive electronic literature search for NOTES was conducted using PubMed and Cochrane Library from March 2002 to February 2016 for papers reporting urologic procedures performed utilizing gastrointestinal tract access. A total of 11 peer-reviewed studies examining utility of gastrointestinal access for NOTES urologic procedures were noted, with the first report in 2007. The procedures reported in the studies were total/radical nephrectomy, partial nephrectomy, adrenalectomy, and prostatectomy. The transgastric approach was identified in five studies examining total/radical nephrectomy (n = 2), partial nephrectomy (n = 1), partial cystectomy (n = 1), and adrenalectomy (n = 1). Six studies evaluated transrectal approach for NOTES, describing total/radical nephrectomy (n = 3), partial nephrectomy (n = 1), robotic nephrectomy with adrenalectomy (n = 1) and prostatectomy (n = 1). Feasibility was reported in all studies. Most studies were preclinical and acute, and limited by concerns regarding restricted instrumentation and infection risk. We concluded that gastrointestinal access for urologic NOTES demonstrates promise as described by outlined feasibility studies in preclinical models. Nonetheless, clinical application awaits further advancements in surgical technology and concerns regarding infectious potential.

Collision Tumor With Renal Cell Carcinoma and Plasmacytoma: Further Evidence of a Renal Cell and Plasma Cell Neoplasm Relationship?

Renal solitary extramedullary plasmacytomas belong to a group of plasma cell neoplasms, which generally have been associated with renal cell carcinoma. We present a case report of a patient with collision tumor histology of extramedullary plasmacytoma and clear cell renal cell carcinoma, the first in the known literature. Standard work-up for a plasma cell neoplasm was conducted and the mass was resected. The patient remains disease-free at 28 months post-surgery. The report calls into question pre-surgical renal mass biopsy protocol and suggests a relationship between renal cell carcinoma and plasma cell neoplasms.