How can the R.E.N.A.L. nephrometry scoring system aid management of a solid renal mass?

OBJECTIVES. To investigate use of the R.E.N.A.L. nephrometry score in relation to the choice of treatment and postoperative complications for renal masses. DESIGN. Case series. SETTING. A tertiary referral hospital in Hong Kong. PATIENTS. Data of patients undergoing nephrectomy were collected retrospectively from a clinical database and analysed. A R.E.N.A.L. nephrometry score was allocated to each renal tumour by a blinded qualified radiologist, utilising computerised imaging systems. Patient demographics, choice of surgery (radical vs partial), and approaches (open vs minimally invasive) were analysed with respect to their R.E.N.A.L. score. RESULTS. In all, 74 patients were included during the study period, of which 38 underwent partial nephrectomy and 36 underwent radical nephrectomy. No differences between the groups were found with respect to patient demographics. There were significant differences between the partial and radical nephrectomy groups in terms of their mean nephrometry score (6.9 vs 9.3, P<0.001). The mean nephrometry sum was also significantly different in the open approach versus the minimally invasive approach in patients having partial nephrectomy (7.8 vs 6.0, P=0.001). There was no difference in the postoperative 90-day morbidity and mortality in the partial nephrectomy and radical nephrectomy groups. CONCLUSIONS. The R.E.N.A.L. nephrometry score of a renal mass correlated significantly with our choice of surgery (partial vs radical) and our approach to surgery (open vs minimally invasive surgery), particularly in the partial nephrectomy group. It does not, however, correlate with postoperative complications. The nephrometry score provides a useful tool for objectively describing renal mass characteristics and enhancing better communication for the operative planning directed at renal masses.published_or_final_versio

Influence of Hospital Volume on Nephrectomy Mortality and Complications: A Systematic Review and Meta-analysis Stratified by Surgical Type

Objectives The provision of complex surgery is increasingly centralised to high volume specialist hospitals. Evidence to support nephrectomy centralisation however has been inconsistent. We conducted a systematic review and meta-analysis to determine the association between hospital case volumes and perioperative outcomes in radical nephrectomy, partial nephrectomy and nephrectomy with venous thrombectomy. Methods Medline, Embase and the Cochrane Library were searched for relevant studies published between 1990 and 2016. Pooled effect estimates for nephrectomy mortality and complications were calculated for each nephrectomy type using the DerSimonian and Laird random-effects model. Sensitivity analyses were performed to examine the effects of heterogeneity on the pooled effect estimates by excluding studies with the heaviest weighting, lowest methodological score, and most likely to introduce bias from misclassification of standardised hospital volume. Results Some 226,372 patients from sixteen publications were included in our review and meta-analysis. Considerable between-study heterogeneity was noted and only a few reported volume-outcome relationships specifically in partial nephrectomy or nephrectomy with venous thrombectomy. High volume hospitals were correlated with a 26% and 52% reduction in mortality for radical nephrectomy (OR 0.74, 95% CI 0.61-0.90, p<0.01) and nephrectomy with venous thrombectomy (OR 0.48, 95% CI 0.29-0.81, p<0.01) respectively. In addition, radical nephrectomy in high volume hospitals was associated with an 18% reduction in complications (OR 0.82, 95% CI 0.73-0.92, p<0.01). No significant volume-outcome relationship in mortality (OR 0.84, 95% CI 0.31-2.26, p=0.73) or complications (OR 0.85, 95% CI 0.55-1.30, p=0.44) was observed for partial nephrectomy. Conclusions Our findings suggest that patients undergoing radical nephrectomy have improved outcomes when treated by high volume hospitals. Evidence of this in partial nephrectomy and nephrectomy with venous thrombectomy is however not yet clear and could be secondary to the low number of studies included and the small patient number in our analyses. Further investigation is warranted to establish the full potential of nephrectomy centralisation particularly as existing evidence is of low quality with significant heterogeneity.This work was supported by Addenbrooke’s Charitable Trust, the Royal College of Surgeons of England and the Urology Foundation. Cancer Research UK Advanced Clinician Scientist Fellowship award (No. C18081/A18180) has supported GL and TS

Robot-assisted versus standard laparoscopic partial nephrectomy: comparison of perioperative outcomes from a single institution

OBJECTIVE: To evaluate the perioperative outcomes of robot-assisted laparoscopic partial nephrectomy and standard laparoscopic partial nephrectomy in a teaching hospital. DESIGN: Retrospective study. SETTING: Division of Urology, Department of Surgery, Queen Mary and Tung Wah hospitals, Hong Kong. PATIENTS: The first 10 consecutive patients who had robot-assisted laparoscopic partial nephrectomy for renal tumours between January 2008 and September 2009 with prospective data collection were evaluated. Their outcomes were compared with the last 10 consecutive patients in our database, who had standard laparoscopic partial nephrectomy between November 2004 and October 2007. MAIN OUTCOME MEASURES: Demographics, tumour characteristics, perioperative outcomes, renal function, and pathological outcomes. RESULTS: There were no differences between the groups with regard to age (63 vs 56 years; P=0.313) and tumour size (2.7 vs 2.8 cm; P=0.895). No significant difference was found between the two groups with respect to the operating room time (376 vs 361 min; P=0.722), estimated blood loss (329 vs 328 mL; P=0.994), and length of hospital stay (7 vs 14 days; P=0.213). A statistically significant shorter mean warm ischaemic time for the robot-assisted group was noted (31 vs 40 minutes; P=0.032). Respective renal functional outcomes as shown by the difference between day 0 and day 60 serum creatinine levels were comparable (+10 vs +7 mmol/L; P=0.605). In both groups, there were no intra-operative complications or instances of surgical margin tumour involvement. Three patients endured postoperative complications in the standard laparoscopic group (a perinephric haematoma, urine leakage, and lymph leakage) compared with one in the robot-assisted group (a perinephric haematoma). These complications all resolved with conservative treatment. CONCLUSIONS: Robot-assisted laparoscopic partial nephrectomy is a technically feasible alternative to standard laparoscopic partial nephrectomy, and provides comparable results. Robot-assisted laparoscopic partial nephrectomy appears to offer the advantage of decreased warm ischaemic time. Longer follow-up is required to assess renal function and oncological outcomes. Further experience and randomised trials are necessary to compare robot-assisted with standard laparoscopic partial nephrectomy.published_or_final_versio

Patients With Kidney Cancer

To develop a preoperative prognostic model in order to predict recurrence-free survival in patients with nonmetastatic kidney cancer.A multi-institutional data base of 1889 patients who underwent surgical resection between 1987 and 2007 for kidney cancer was retrospectively analyzed. Preoperative variables were defined as age, gender, presentation, size, presence of radiological lymph nodes and clinical stage. Univariate and multivariate analyses of the variables were performed using the Cox proportional hazards regression model. A model was developed with preoperative variables as predictors of recurrence after nephrectomy. Internal validation was performed by Harrells concordance index.The median follow-up was 23.6 months (1222 months). During the follow-up, 258 patients (13.7) developed cancer recurrence. The median follow-up for patients who did not develop recurrence was 25 months. The median time from surgery to recurrence was 13 months. The 5-year freedom from recurrence probability was 78.6. All variables except age were associated with freedom from recurrence in multivariate analyses (P 0.05). Age was marginally significant in the univariate analysis. All variables were included in the predictive model. The calculated c-index was 0.747.This preoperative model utilizes easy to obtain clinical variables and predicts the likelihood of development of recurrent disease in patients with kidney tumors

Accuracy of magnetic resonance imaging to identify pseudocapsule invasion in renal tumors

Purpose: To evaluate accuracy of MRI in detecting renal tumor pseudocapsule (PC) invasion and to propose a classification based on imaging of PC status in patients with renal cell carcinoma. Methods: From January 2017 to June 2018, 58 consecutive patients with localized renal cell carcinoma were prospectively enrolled. MRI was performed preoperatively and PC was classified, according to its features, as follows: MRI-Cap 0 (absence of PC), MRI-Cap 1 (presence of a clearly identifiable PC), MRI-Cap 2 (focally interrupted PC), and MRI-Cap 3 (clearly interrupted and infiltrated PC). A 3D image reconstruction showing MRI-Cap score was provided to both surgeon and pathologist to obtain complete preoperative evaluation and to compare imaging and pathology reports. All patients underwent laparoscopic partial nephrectomy. In surgical specimens, PC was classified according to the renal tumor capsule invasion scoring system (i-Cap). Results: A concordance between MRI-Cap and i-Cap was found in 50/58 (86%) cases. ρ coefficient for each MRI-cap and iCap categories was: MRI-Cap 0: 0.89 (p &lt; 0.0001), MRI-Cap1: 0.75 (p &lt; 0.0001), MRI-Cap 2: 0.76 (p &lt; 0.0001), and MRI-Cap3: 0.87 (p &lt; 0.0001). Sensitivity, specificity, positive predictive value, negative predictive value, and AUC were: MRI-Cap 0: Se 97.87% Spec 83.3%, PPV 95.8%, NPV 90.9%, and AUC 90.9; MRI-Cap 1: Se 77% Spec 95.5%, PPV 83.3%, NPV 93.5%, and AUC 0.86; MRI-Cap 2- iCap 2: Se 88% Spec 90%, PPV 79%, NPV 95%, and AUC 0.89; MRI-Cap 3: Se 94% Spec 95%, PPV 88%, NPV 97%, and AUC 0.94. Conclusions: MRI-Cap classification is accurate in evaluating renal tumor PC features. PC features can provide an imaging-guided landmark to figure out where a minimal margin could be preferable during nephron-sparing surgery

Oncogenic microRNAs characterization in clear cell renal cell carcinoma

A key challenge for the improvement of clear cell renal cell carcinoma (ccRCC) management could derive from a deeper characterization of the biology of these neoplasms that could greatly improve the diagnosis, prognosis and treatment choice. The aim of this study was to identify specific miRNAs that are deregulated in tumor vs. normal kidney tissues and that could impact on the biology of ccRCC. To this end we selected four miRNAs (miR-21-5p, miR-210-3p, miR-185-5p and miR-221-3p) and their expression has been evaluated in a retrospective cohort of formalin-fixed paraffin-embedded (FFPE) tissues from 20 ccRCC patients who underwent surgical nephrectomy resection. miR-21-5p and miR-210-3p resulted the most significantly up-regulated miRNAs in this patient cohort, highlighting these onco-miRNAs as possible relevant players involved in ccRCC tumorigenesis. Thus, this study reports the identification of specific oncogenic miRNAs that are altered in ccRCC tissues and suggests that they might be useful biomarkers in ccRCC management

Post partial nephrectomy surveillance imaging: an evidence-based approach.

To ensure the early detection of recurrent disease, all patients should undergo routine surveillance following partial nephrectomy for renal cell carcinoma. In order to optimize resource allocation and avoid unnecessary radiation exposure, the frequency and duration of surveillance should be tailored to the individual patient's risk of cancer recurrence. The evidence for surveillance after partial nephrectomy is presented reviewing the current literature on prognostic models and proposed surveillance protocols based on the timing and patterns of renal cell carcinoma recurrence. In addition, we review recent guidelines on post partial nephrectomy surveillance as well as the literature on novel imaging techniques that may aid in early disease discovery

Partial nephrectomy for T1 renal cancer can achieve an equivalent oncological outcome to radical nephrectomy with better renal preservation: the way to go

INTRODUCTION: Patients who undergo partial nephrectomy have been shown to be at decreased risk of renal impairment compared with radical nephrectomy. We examined the oncological outcome of patients in our centre who underwent partial or radical nephrectomy for T1 renal cancer (7 cm or smaller), and compared the likelihood of developing chronic kidney disease. METHODS: This historical cohort study with internal comparison was conducted in a tertiary hospital in Hong Kong. A cohort of 86 patients with solitary T1 renal cancer and a normal contralateral kidney who underwent radical (38 patients) or partial (48 patients) nephrectomy between January 2005 and December 2010 was included. The overall and cancer-free survival, change in glomerular filtration rate, and new onset of chronic kidney disease were compared between the radical and partial nephrectomy groups. RESULTS: A total of 32 (84%) radical nephrectomy patients and 43 (90%) partial nephrectomy patients were alive by 31 December 2012. The mean follow-up was 43.5 (standard deviation, 22.4) months. There was no significant difference in overall survival (P=0.29) or cancer-free survival (P=0.29) between the two groups. Both groups enjoyed good oncological outcome with no recurrence in the partial nephrectomy group. Overall, 18 (21%) patients had pre-existing chronic kidney disease. The partial nephrectomy group had a significantly smaller median reduction in glomerular filtration rate (12.6% vs 35.4%; P<0.001), and radical nephrectomy carried a significantly higher risk of developing chronic kidney disease (hazard ratio=5.44; 95% confidence interval, 1.26-23.55; P=0.02). CONCLUSIONS: Compared with radical nephrectomy, partial nephrectomy can prevent chronic kidney disease and still achieve an excellent oncological outcome for T1 renal tumours, in particular T1a tumours and tumours with a low R.E.N.A.L. score.published_or_final_versio

Clinical outcome and prognostic factors in renal medullary carcinoma: a pooled analysis from 18 years of medical literature

INTRODUCTION: We describe clinical features and prognostic factors of renal medullary carcinoma (RMC) by performing a pooled analysis of all reported cases since 1995. METHODS: A systematic search was performed to identify all articles describing patients with medullary renal cancer until February 2013. Survivals were estimated using Kaplan-Meier method with 95% confidence intervals and compared across the groups using the log-rank test. The following factors were evaluated using the Cox proportional hazards model: association of extension of disease at diagnosis, response to therapy, and surgical treatment of primary tumour with overall. RESULTS: A total 47 articles were selected; these described 165 patients with RMC plus 1 from our centre. The median age was 21 years and 98% of cases had the sickle cell trait. The mean size of the primary tumours was 6.0 cm, with an involvement of loco-regional lymph nodes in 71% of cases. The overall survival at diagnosis was 4.0 months in metastatic patients and 17.0 months in non-metastatic patients. Patients who received platinum-paclitaxel-gemcitabine had longer control of the disease when compared to topoisomerase inhibitors or targeted therapies. The multivariate analysis confirmed that the advanced stage at diagnosis increased the risk of death of about threefold. CONCLUSION: RMC is a tumour with poorer prognosis; based on these results, platinum-based chemotherapy is the preferred systemic treatment. Even if radical nephrectomy as an up-front strategy did not report a survival benefit, it may be considered to palliate local symptoms and to perform a correct diagnosis