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Article of the Week: Trifecta and Optimal Peri-operative outcomes of Robotic and Laparoscopic Partial Nephrectomy In Surgical Treatment Of SRMs

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Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Month heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Jihad Kaouk discussing his paper. 

If you only have time to read one article this week, it should be this one.

Trifecta and Optimal Peri-operative outcomes of Robotic and Laparoscopic Partial Nephrectomy In Surgical Treatment Of Small Renal Masses: A Multi-Institutional Study

 

Homayoun Zargar*, Mohamad E. Allaf†, Sam Bhayani‡, Michael Stifelman§, Craig Rogers, Mark W. Ball†, Jeffrey Larson‡
, Susan Marshall§, Ramesh Kumar¶ and Jihad H. Kaouk*

 

*Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, †The Johns Hopkins Medical Institutions, James Buchanan Brady Urological Institute, Baltimore, MD, ‡Dept. of Urology, Washington University School of Medicine, St. Louis, MO, §Dept. of Urology, New York University School of Medicine, New York, NY, and Henry Ford Health System, Vattikuti Urology Institute, Detroit, MI, USA

 

Read the full article
OBJECTIVE

To compare the perioperative outcomes of robotic partial nephrectomy (RPN) with laparoscopic PN (LPN) performed for small renal masses (SRMs), in a large multi-institutional series and to define a new composite outcome measure, termed ‘optimal outcome’ for the RPN group.

PATIENTS AND METHODS

Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high-volume centres from 2004 to mid-2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of ≤25 min. The ‘optimal outcome’ was defined as achievement of Trifecta with addition of 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading. Univariable and multivariable analysis were used to identify factors predicting Trifecta and ‘optimal outcome’ achievement.

RESULTS

In all, 1185 RPN and 646 LPN met our inclusion criteria. Patients in the RPN group were older and had a higher median Charlson comorbidity index and higher R.E.N.A.L. nephrometry score. The RPN group had lower warm ischaemia time (18 vs 26 min), overall complication rate (16.2% vs 25.9%), and positive surgical margin rate (3.2% vs. 9.7%). There was a significantly higher Trifecta rate for RPN (70% vs 33%) and the rate of achievement of ‘optimal outcome’ for the RPN group was 38.5%.

CONCLUSIONS

In this large multi-institutional series RPN was superior to LPN for perioperative surgical outcomes measured by Trifecta. Patients in the RPN group had better outcomes for all three components of Trifecta compared with their LPN counterparts. Our more strict definition for ‘optimal outcome’ might be a better tool for assessing perioperative and functional outcomes after minimally invasive PN. This tool needs to be externally validated.

 

Read more articles of the week

Editorial: Robotic Partial Nephrectomy: The Treatment of Choice for Minimally Invasive Nephron Sparing Surgery

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Early in the adoption of robotic partial nephrectomy (RPN) as an alternative to laparoscopic PN (LPN) for the treatment of small renal masses, several of the current authors presented a similar comparison of LPN and RPN. They found RPN to result in shorter hospital stay, less blood loss, and shorter warm ischaemia time (WIT) compared with LPN [1]. They discovered that RPN outcomes were not dependent on the complexity of the tumour, which clearly impacted LPN results. They concluded that RPN is a safe and viable alternative to LPN and offered benefits even for experienced laparoscopic surgeons.

The current report in this edition of BJUI furthers the comparison of RPN and LPN and expands the assessment to include five high-volume centres of excellence in robotic surgery [2]. This retrospective, multi-institutional review of 1 185 RPN and 646 LPN represents the largest comparison to date of these two approaches for minimally invasive PN. Despite higher patient comorbidities and R.E.N.A.L. nephrometry scores in the RPN patients compared with the LPN group, there were fewer overall complications (16.2% vs 25.9%), a lower positive surgical margin rate (3.2% vs 9.7%) and a lower WIT (18 vs 26 min). They also found a much higher percentage of RPN patients (70% vs 33%) meeting the Trifecta criteria, defined as negative surgical margins, no perioperative complications, and a WIT of ≤25 min. Finally, the authors introduce a more stringent composite measure of ‘optimal outcomes’, which is the Trifecta with the addition of 90% estimated GFR preservation and no chronic kidney disease upgrading. They report 38.5% of RPN patients meeting optimal outcomes compared with 24.1% for LPN.

This study clearly demonstrates the superiority of RPN over LPN and is supported by other single-surgeon reports [3]. These results also exceed those reported for open PN with the added benefit of reduced hospital stay [4]. However, it is important to recognise that these results represent a mature experience with RPN by the leaders in the field of robotic renal surgery. Many of these authors pioneered the techniques currently used for RPN, and therefore these results may not apply to centres without the same experience or case volumes. One limitation of this report is the non-concurrent experience of LPN and RPN. The results of RPN came after an initial experience with LPN and therefore the outcomes of RPN may have benefitted from the lessons learned with LPN prior to RPN.

Reporting surgical outcomes as composite results, such as the Trifecta, allows for comparison between reports and sets an outcomes bar for future studies. Most composite measures include assessment of surgical margin status and complications, but there is no current agreement as to the optimal measure of renal functional outcomes. The current Trifecta used a WIT of ≤25 min as a measure of renal function impact, while the margin, ischaemia, and complications (MIC) score uses a WIT of <20 min [5], and others have used 90% renal parenchyma preservation as part of the Trifecta [6]. The impact of WIT on renal function has been questioned given the recently recognised importance of preserved renal parenchyma as an important predictor of renal function after PN [7]. Until there is consensus as to the best measure of renal function after nephron-sparing surgery, composite outcomes such as the Trifecta and the optimal outcomes as described by the authors will have limited utility.

Read the full article
James Porter
Robotic Surgery, Swedish Medical Center, Seattle , WA, USA
References

 

1 Benway BM, Bhayani SB, Rogers CG et al. Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. J Urol 2009; 182:866–72

 

2 Zargar H, Allaf M, Bhayani S et al. Trifecta and optimal perioperative outcomes of robotic and laparoscopic partial nephrectomy in surgical treatment of small renal masses: a multi-institutional study. BJU Int 2015; 407–14

 

3 Mullins JK, Feng T, Pierorazio PM, Patel HD, Hyams ES, Allaf ME. Comparative analysis of minimally invasive partial nephrectomy techniques in the treatment of localized renal tumors. Urology 2012; 80: 316–21

 

4 Gill IS, Kavoussi LR, Lane BR et al. Comparison of 1800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol 2007; 178: 41–6

 

5 Buffi N, Lista G, Larcher A et al. Margin, ischemia, and complications (MIC) score in partial nephrectomy: a new system for evaluating achievement of optimal outcomes in nephron-sparing surgery. Eur Urol 2012; 62: 617–8

 

6 Hung AJ, Cai J, Simmons MN, Gill IS. “Trifecta” in partial nephrectomy. J Urol 2013; 189: 36–42

 

7 Mir MC, Campbell RA, Sharma N et al. Parenchymal volume preservation and ischemia during partial nephrectomy: functional and volumetric analysis. Urology 2013; 82: 263–8

 

Video: Trifecta and Optimal Peri-operative outcomes of Robotic and Laparoscopic Partial Nephrectomy In Surgical Treatment Of SRMs

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Trifecta and Optimal Peri-operative outcomes of Robotic and Laparoscopic Partial Nephrectomy In Surgical Treatment Of Small Renal Masses: A Multi-Institutional Study

 

Homayoun Zargar*, Mohamad E. Allaf†, Sam Bhayani‡, Michael Stifelman§, Craig Rogers, Mark W. Ball†, Jeffrey Larson‡, Susan Marshall§, Ramesh Kumar¶ and Jihad H. Kaouk*

 

*Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, †The Johns Hopkins Medical Institutions, James Buchanan Brady Urological Institute, Baltimore, MD, ‡Dept. of Urology, Washington University School of Medicine, St. Louis, MO, §Dept. of Urology, New York University School of Medicine, New York, NY, and Henry Ford Health System, Vattikuti Urology Institute, Detroit, MI, USA

 

Read the full article
OBJECTIVE

To compare the perioperative outcomes of robotic partial nephrectomy (RPN) with laparoscopic PN (LPN) performed for small renal masses (SRMs), in a large multi-institutional series and to define a new composite outcome measure, termed ‘optimal outcome’ for the RPN group.

PATIENTS AND METHODS

Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high-volume centres from 2004 to mid-2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of ≤25 min. The ‘optimal outcome’ was defined as achievement of Trifecta with addition of 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading. Univariable and multivariable analysis were used to identify factors predicting Trifecta and ‘optimal outcome’ achievement.

RESULTS

In all, 1185 RPN and 646 LPN met our inclusion criteria. Patients in the RPN group were older and had a higher median Charlson comorbidity index and higher R.E.N.A.L. nephrometry score. The RPN group had lower warm ischaemia time (18 vs 26 min), overall complication rate (16.2% vs 25.9%), and positive surgical margin rate (3.2% vs. 9.7%). There was a significantly higher Trifecta rate for RPN (70% vs 33%) and the rate of achievement of ‘optimal outcome’ for the RPN group was 38.5%.

CONCLUSIONS

In this large multi-institutional series RPN was superior to LPN for perioperative surgical outcomes measured by Trifecta. Patients in the RPN group had better outcomes for all three components of Trifecta compared with their LPN counterparts. Our more strict definition for ‘optimal outcome’ might be a better tool for assessing perioperative and functional outcomes after minimally invasive PN. This tool needs to be externally validated.

 

Read more articles of the week

Article of the Week: Perioperative and functional outcomes of elective RAPN for renal tumors with high surgical complexity

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Perioperative and renal functional outcomes of elective robot-assisted partial nephrectomy for renal tumors with high surgical complexity

Alessandro Volpe*†, Diletta Garrou*‡, Daniele Amparore*‡, Geert De Naeyer*, Francesco Porpiglia‡, Vincenzo Ficarra*§ and Alexandre Mottrie*

*Division of Urology, O.L.V. Vattikuti Robotic Surgery Institute, Aalst, Belgium, †Division of Urology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, ‡Division of Urology, University of Torino, San Luigi Hospital, Orbassano, and §Division of Urology, University of Udine, Udine, Italy

Read the full article
OBJECTIVE

To evaluate the perioperative, postoperative and functional outcomes of robot-assisted partial nephrectomy (RAPN) for renal tumours with high surgical complexity at a large volume centre.

PATIENTS AND METHODS

Perioperative and functional outcomes of RAPNs for renal tumours with a Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score of ≥10 performed at our institution between September 2006 and December 2012 were collected in a prospectively maintained database and analysed. Surgical complications were graded according to the Clavien-Dindo classification. Serum creatinine and estimated glomerular filtration rate (eGFR) were assessed at the third postoperative day and 3–6 months after RAPN.

RESULTS

In all, 44 RAPNs for renal tumours with PADUA scores of ≥10 were included in the analysis; 23 tumours (52.3%) were cT1b. The median (interquartile range; range) operative time, estimated blood loss and warm ischaemia time (WIT) were 120 (94, 132; 60–230) min, 150 (80, 200; 25–1200) mL and 16 (13.8, 18; 5–35) min, respectively. Two intraoperative complications occurred (4.5%): one inferior vena caval injury and one bleed from the renal bed, which were both managed robotically. There were postoperative complications in 10 patients (22.7%), of whom four (9.1%) were high Clavien grade, including two bleeds that required percutaneous embolisation, one urinoma that resolved with ureteric stenting and one bowel occlusion managed with laparoscopic adhesiolysis. Two patients (4.5%) had positive surgical margins (PSMs) and were followed expectantly with no radiological recurrence at a mean follow-up of 23 months. The mean serum creatinine levels were significantly increased after surgery (121.1 vs 89.3 μmol/L; P = 0.001), but decreased over time, with no significant differences from the preoperative values at the 6-month follow-up (96.4 vs 89.3 μmol/L; P = 0.09). The same trend was seen for eGFR.

CONCLUSION

In experienced hands RAPN for renal tumours with a PADUA score of ≥10 is feasible with short WIT, acceptable major complication rate and good long-term renal functional outcomes. A slightly higher risk of PSMs can be expected due to the high surgical complexity of these lesions. The robotic technology allows a safe expansion of the indications of minimally invasive PN to anatomically very challenging renal lesions in referral centres.

Read more articles of the week

Editorial: Complex tumours, partial nephrectomy and functional outcomes

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In the paper by Volpe et al. [1], excellent renal functional outcomes are associated with partial nephrectomy in patients with high PADUA score cancers. The study is notable because it shows that, even in patients who are typically considered candidates for radical nephrectomy, partial nephrectomy can maintain excellent estimated GFR (eGFR) and outcomes; however, because we perform nephron-sparing procedures on patients who may also be candidates for radical nephrectomy, we must consider the varied nature of some of the data on partial nephrectomy.

The literature on renal ischaemia and functional outcomes is heterogeneous and highly debated [2]. There have been several contradictory studies and changes over time in the literature based on technology, surgeon, centre, measurement and, now, correlation with parenchyma-sparing.

A study conducted by the European Organisation for the Research and Treatment of Cancer (EORTC) compared radical nephrectomy (essentially an ischaemic time of infinity) and partial nephrectomy, reporting a 10-year overall survival benefit for patients treated with radical nephrectomy [3]. Nevertheless, this oft-criticized randomised trial also showed better eGFR in partial nephrectomy. The survival benefit reported in that study is countered by population-based studies suggesting that partial nephrectomy may still be a better option when feasible [4]. Unfortunately, these population-based studies may be considered to provide a lower level of evidence than a randomised study, and are also prone to several biases, the most notable being selection of both patients and centres. Surgeons may be more likely to perform nephron-sparing in patients in lower-risk groups. There are also other questions to consider. If a patient is more likely to be referred to a larger centre for partial nephrectomy, are they not also likely to be referred for their coronary artery bypass, aortic surgery, general medical care and even emergency care? Are these patients more likely to seek out second opinions for all of their medical care? Will this affect mortality? Are they more motivated and engaged in their own overall healthcare? These are just a few of the confounding factors that could influence outcomes and are difficult to control in population-based studies. Nevertheless, I am a firm believer in partial nephrectomy, and particularly in preserving renal function, as the better choice for the treatment of both straightforward and complex lesions. It will be difficult, however, to completely negate the implications of the EORTC trial.

Does reasonable ischaemic time affect eGFR outcome? The present study by Volpe et al. [1] would suggest that reasonable ischaemic times are completely acceptable. Several contradictory studies point out the benefits and risks of a limited or minimized clamp time for partial nephrectomy. Another separate paper by White et al. [5] is consistent with other studies that show that a clamped partial nephrectomy, even for high complexity masses, results in a minimal loss of renal function, if at all. Although there is also enthusiasm for a zero ischaemia technique, it is critical to point out that this may be surgeon-, patient-, technique- and institution-dependent. Ultimately, however, we are splitting hairs over a few points of eGFR. The real issue with long-term GFR outcomes in our patients is not only the impact of a few minutes of renal ischaemia, but also control of hypertension, diabetes and their role in medical renal disease. There is an absence of urological literature that controls for patients’ glycated haemoglobin levels or measures hypertension monthly and records the response to medical therapy. These critical pieces of information confound all eGFR and comparative measurements and make it difficult to compare published outcomes. Perhaps the best medical advice we can give patients is to diet, exercise and eat healthily for better overall health. In some sense, this advice may be far more important than the decision of partial vs radical nephrectomy for a complex mass.

What are the logical conclusions of these dilemmas? Clamped partial nephrectomy is possible in complex cases, and the procedure salvages eGFR. Further refinements are also interesting academically, including papers on parenchyma-sparing. Nevertheless, if we are serious about ‘healthy kidneys’, we might take a holistic approach and encourage our patients to pursue a healthier lifestyle so they can bolster lifelong preservation of renal function and general wellness. Would the effect be more profound than a few minutes of ischaemic time? I am betting it would.

Read the full article

Sam B. Bhayani 

Division of Urological Surgery, Washington University School of Medicine and Barnes-Jewish West County Hospital, St Louis, MO, USA

References

1 Volpe A, Garrou D, Amparore D et al. Perioperative and renal functional outcomes of elective robot-assisted partial nephrectomy for renal tumors with high surgical complexity. BJU Int 2014; 114: 903–9

2 Lane BR, Russo P, Uzzo RG et al. Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant roles of nonmodifiable factors in determining ultimate renal function. J Urol 2011; 185: 421–7

3 Van Poppel H, Da Pozzo L, Albrecht W et al. A prospective, randomized EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2011; 59: 543–52

4 Sun M, Trinh Q-D, Bianchi M et al. A non-cancer related survival benefit is associated with partial nephrectomy. Eur Urol 2012; 61: 725–31

5 White MA, Georges-Pascal H, Autorino R et al. Outcomes of robotic partial nephrectomy for renal masses with nephrometry score of ≥ 7. Urology 2011; 77: 809–13

 

Article of the week: Nephron-sparing management vs radical nephroureterectomy

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Jay Simhan dicsussing his paper.

If you only have time to read one article this week, it should be this one.

Nephron-sparing management vs radical nephroureterectomy for low- or moderate-grade, low-stage upper tract urothelial carcinoma

Jay Simhan, Marc C. Smaldone, Brian L. Egleston*, Daniel Canter†, Steven N. Sterious, Anthony T. Corcoran, Serge Ginzburg, Robert G. Uzzo and Alexander Kutikov

Division of Urologic Oncology, Departments of Surgical Oncology, *Biostatistics, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA and †Department of Urology, Emory University School of Medicine, Atlanta, GA, USA

Read the full article
OBJECTIVE

• To compare overall and cancer-specific outcomes between patients with upper tract urothelial carcinoma (UTUC) managed with either radical nephroureterectomy (RNU) or nephron-sparing measures (NSM) using a large population-based dataset.

PATIENTS AND METHODS

• Using Surveillance, Epidemiology, and End Results (SEER) data, patients diagnosed with low- or moderate-grade, localised non-invasive UTUC were stratified into two groups: those treated with RNU or NSM (observation, endoscopic ablation, or segmental ureterectomy).

• Cancer-specific mortality (CSM) and other-cause mortality (OCM) rates were determined using cumulative incidence estimators. Adjusting for clinical and pathological characteristics, the associations between surgical type, all-cause mortality and CSM were tested using Cox regressions and Fine and Gray regressions, respectively.

RESULTS

• Of 1227 patients [mean (sd) age 70.2 (11.00) years, 63.2% male] meeting inclusion criteria, 907 (73.9%) and 320 (26.1%) patients underwent RNU and NSM for low- or moderate-grade, low-stage UTUC from 1992 to 2008.

• Patients undergoing NSM were older (mean age 71.6 vs 69.7 years, P < 0.01) with a greater proportion of well-differentiated tumours (26.3% vs 18.0%, P = 0.001).

• While there were differences in OCM between the groups (P < 0.01), CSM trends were equivalent. After adjustment, RNU treatment was associated with improved non-cancer cause survival [hazard ratio (HR) 0.78, confidence interval [CI] 0.64–0.94) while no association with CSM was demonstrable (HR 0.89, CI 0.63–1.26).

CONCLUSIONS

• Patients with low- or moderate-grade, low-stage UTUC managed through NSM are older and are more likely to die of other causes, but they have similar CSM rates to those patients managed with RNU.

• These data may be useful when counselling patients with UTUC with significant competing comorbidities.

Read more articles of the week

Editorial: Upper tract urothelial carcinoma: do we really need to burn down the house?

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In this issue, Simhan et al. [1] use the Surveillance, Epidemiology, and End Results (SEER) database to compare outcomes of nephron-sparing and radical extirpative therapy for upper tract urothelial carcinoma (UTUC). Their study sheds some well-needed light on a difficult clinical dilemma.

A diagnosis of low- or moderate-grade, low-stage UTUC is akin to finding a spot of suspicious green mould on your attic drywall. The scale and potential danger of the problem may not be immediately apparent and both patient and urologist must make tough choices with incomplete information. Spot treat the problem and preserve nephrons via endoscopic or segmental resection or burn down the house with radical nephroureterectomy to minimise recurrence and progression risk? With only relatively small datasets for guidance and the uncertainty of endoscopic biopsy, many urologists have a low threshold to proceed with radical therapy, perhaps unnecessarily.

Simhan et al. [1] identified 1227 patients in the SEER dataset with low- or moderate-grade, localised, non-invasive UTUC who were treated either with nephron-sparing procedures (endoscopic resection or segmental ureterectomy) or nephroureterectomy between 1992 and 2008. For this cohort, radical therapy with nephroureterectomy imparted no advantage in cancer-specific survival. Patients undergoing nephron sparing were slightly older and did experience higher non-cancer specific mortality. This may reflect an underlying bias to offer nephron sparing to older patients with a greater burden of comorbidities and shorter life expectancy. These results corroborate another large SEER study from 2010, which documented no difference in cancer-specific mortality when comparing segmental resection with nephroureterectomy for T1–T4 N0M0 urothelial carcinoma of the ureter [2].

Population-based tumour registry studies are complementary to institutional series and are particularly valuable for rare tumours like UTUC. However, they have their limitations and these are outlined clearly in the Simhan et al. [1] article. Most notable are the lack of linked comorbidity information and the inability to separate segmental resection from endoscopic management in the nephron-sparing group. We should avoid the temptation to broaden indications for endoscopic resection to all patients with low-grade, low-stage UTUC of the renal pelvis and calyces. After all, the authors present no data on: (i) local recurrence and reoperation rates, (ii) progression to radical nephroureterectomy or (iii) correlation between endoscopic biopsy results and the ultimate pathology from nephroureterectomy specimens.

Over the past decade, there has been a progressive movement toward nephron-sparing approaches for treatment of T1 RCC, even in the context of a normal contralateral kidney. This transition has been fuelled by data showing the substantial negative impact of chronic kidney disease (CKD) on cardiovascular events and overall mortality [3]. Broader application of this philosophy to the treatment of low- or moderate-grade, low-stage UTUC would be a natural next step. This is particularly true given the advantage of maximising nephrons should disease progression necessitate platinum-based chemotherapy.

However, endoscopic resection of UTUC carries a much higher burden of local recurrence (20–85%) [4], than does partial nephrectomy for RCC. Patients with UTUC often require multiple serial endoscopic resections and years of complicated and costly surveillance. More recent data also suggests that surgically induced CKD may not carry the same risk of progression and mortality as medical CKD [5]. Perhaps burning down the house is not as potentially destructive as we once thought?

With these caveats firmly in mind, the Simhan et al. [1] study does support a growing appreciation that nephron-sparing approaches to low- or moderate-grade, low-stage UTUC do not worsen cancer-specific mortality. Although these findings are encouraging, I agree with the authors that patient selection for nephron sparing should continue to be informed by clinical judgment and adherence to published treatment guidelines [6].

Richard E. Link
Associate Professor of Urology, Director, Division of Endourology and Minimally Invasive Surgery, Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA

References

  2. Jeldres C, Lughezzani G, Sun M et al. Segmental ureterectomy can safely be performed in patients with transitional cell carcinoma of the ureter. J Urol 2010; 183: 1324–1329
  3. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351: 1296–1305
  4. Bagley DH, Grasso M 3rd. Ureteroscopic laser treatment of upper urinary tract neoplasms. World J Urol 2010; 28: 143–149
  5. Lane BR, Campbell SC, Demirjian S, Fergany AF. Surgically induced chronic kidney disease may be associated with a lower risk of progression and mortality than medical chronic kidney disease. J Urol 2013; 189: 1649–1655
  6. Roupret M, Zigeuner R, Palou J et al. European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. Eur Urol 2011; 59: 584–594

 

Video: Nephron sparing vs radical nephroureterectomy for UTUC

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Nephron-sparing management vs radical nephroureterectomy for low- or moderate-grade, low-stage upper tract urothelial carcinoma

Jay Simhan, Marc C. Smaldone, Brian L. Egleston*, Daniel Canter†, Steven N. Sterious, Anthony T. Corcoran, Serge Ginzburg, Robert G. Uzzo and Alexander Kutikov

Division of Urologic Oncology, Departments of Surgical Oncology, *Biostatistics, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA and †Department of Urology, Emory University School of Medicine, Atlanta, GA, USA

Read the full article
OBJECTIVE

• To compare overall and cancer-specific outcomes between patients with upper tract urothelial carcinoma (UTUC) managed with either radical nephroureterectomy (RNU) or nephron-sparing measures (NSM) using a large population-based dataset.

PATIENTS AND METHODS

• Using Surveillance, Epidemiology, and End Results (SEER) data, patients diagnosed with low- or moderate-grade, localised non-invasive UTUC were stratified into two groups: those treated with RNU or NSM (observation, endoscopic ablation, or segmental ureterectomy).

• Cancer-specific mortality (CSM) and other-cause mortality (OCM) rates were determined using cumulative incidence estimators. Adjusting for clinical and pathological characteristics, the associations between surgical type, all-cause mortality and CSM were tested using Cox regressions and Fine and Gray regressions, respectively.

RESULTS

• Of 1227 patients [mean (sd) age 70.2 (11.00) years, 63.2% male] meeting inclusion criteria, 907 (73.9%) and 320 (26.1%) patients underwent RNU and NSM for low- or moderate-grade, low-stage UTUC from 1992 to 2008.

• Patients undergoing NSM were older (mean age 71.6 vs 69.7 years, P < 0.01) with a greater proportion of well-differentiated tumours (26.3% vs 18.0%, P = 0.001).

• While there were differences in OCM between the groups (P < 0.01), CSM trends were equivalent. After adjustment, RNU treatment was associated with improved non-cancer cause survival [hazard ratio (HR) 0.78, confidence interval [CI] 0.64–0.94) while no association with CSM was demonstrable (HR 0.89, CI 0.63–1.26).

CONCLUSIONS

• Patients with low- or moderate-grade, low-stage UTUC managed through NSM are older and are more likely to die of other causes, but they have similar CSM rates to those patients managed with RNU.

• These data may be useful when counselling patients with UTUC with significant competing comorbidities.

Read more articles of the week

Article of the week: Repeat RAPN: Feasibility and early outcomes

/3 Comments/by

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Repeat robot-assisted partial nephrectomy (RAPN): feasibility and early outcomes

Riccardo Autorino, Ali Khalifeh, Humberto Laydner, Dinesh Samarasekera, Emad Rizkala, Remi Eyraud, Georges-Pascal Haber, Robert J. Stein and Jihad H. Kaouk

Center for Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

Read the full article
OBJECTIVE

• To demonstrate the feasibility, and to report our single-centre perioperative outcomes of repeat robot-assisted partial nephrectomy (RAPN).

PATIENTS AND METHODS

• From June 2006 to June 2012, 490 patients underwent RAPN for a renal mass at our centre. Of these patients, nine who had undergone previous ipsilateral nephron-sparing surgery (NSS) were included in the analysis.

• Patient charts were reviewed to obtain demographic data, preoperative surgical history, operative details, and postoperative outcomes and follow-up data.

RESULTS

• In all, 12 tumours were removed in nine patients (median age 69 years; six female). A third of the operations were performed on patients with a solitary kidney. The median (range) R.E.N.A.L. nephrometry score for the resected masses was 7 (4–8).

• The warm ischaemia time was 17.5 min and in three of the nine patients an unclamped procedure was performed. No intraoperative complications were registered, whereas only two minor complications occurred postoperatively. There were no renal unit losses. All surgical margins were negative.

• There was no significant difference between mean preoperative and latest postoperative mean estimated glomerular filtration rates (70.5 vs 63.5 mL/min/1.73m2, P > 0.05).

• At a mean (sd) follow-up of 8.3 (13) months, eight of the nine patients with a pathology diagnosis of malignant neoplasm were alive and free from disease at the latest follow-up.

CONCLUSION

• Although technically more demanding, repeat RAPN can be safely and effectively performed in patients presenting with local recurrence after primary NSS for kidney cancer.

 

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Editorial: Robot-assisted partial nephrectomy in patients with recurrent disease: fiction or fact?

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In recent decades, the detection of small renal masses (SRMs) has steadily increased with an accompanying shift of treatment towards partial nephrectomy (PN). Indications for PN have successfully expanded to more challenging cases, and robot-assisted PN (RAPN), in particular, has attracted increasing attention (BJUI, Eur Urol); however, despite excellent cure rates for PN, parallel to the increasing number of patients with SRMs undergoing PN, cases of ipsilateral recurrence after PN are also expected to rise. In addition to the incomplete surgical removal of the primary tumour, unknown multifocality or the development of new tumours or metastasis, in a minority of cases recurrence originates at the previous surgical bed and can be considered a proper local recurrence. Retreatment in these patients represents a specific challenge with radical nephrectomy (RN), ablative treatment, repeat PN, and active surveillance in selected cases as therapeutic options. RN should be considered the least attractive option because of the further damage to renal function that it entails, yet it represents one of the most selected options worldwide. Besides ablative techniques, which should be considered under investigational circumstances only, repeat PN is one of the possible options, especially in cases of recurrences attributable to multifocality or bilateral nature.

Repeat open as well as laparoscopic PN (LPN) have been reported sparsely in the literature, but were shown to be associated with good functional and oncological outcomes given adequate laparoscopic experience and patient selection. Such procedures, however, might be challenging and fraught with complications. The role of repeat RAPN (as well as the role of repeat open PN) in this situation is yet to be defined. Nevertheless, given that current data show RAPN to be a more attractive minimally invasive PN technique compared with its standard laparoscopic counterpart, providing equal or better perioperative outcomes, its advantages may even be greater when repeat PN is indicated.

In the current issue of the journal, Autorino et al. report the first study on functional and oncological outcomes and feasibility of repeat RAPN in patients with recurrence after previous PN. Of 490 patients treated with RAPN, nine patients underwent RAPN for recurrent disease at a median time of 39.4 months after previous open or LPN. A total of 12 tumours were removed in these patients, and one third of operations were performed on solitary kidneys. No intra-operative complications were observed, and only two minor complications occurred postoperatively, which were managed conservatively. With regard to functional outcomes, there was a nonsignificant median postoperative decrease in estimated GFR of 7%. More importantly, all patients preserved adequate renal function, which meant that renal replacement therapy was not necessary. With regard to oncological outcomes, all surgical margins were negative and no recurrence was reported.

The results of another study cohort of five patients undergoing repeat RAPN for recurrent disease after open or LPN has recently been published by Jain et al. In their series, surgery was completed in all patients without conversion to RN or an open procedure; furthermore, no complications were reported and the median decrease in GFR was 10%.

Importantly, both series suffer from retrospective evaluation of selective and small sample sizes with a short follow-up, and comparative analysis with other treatment options was not performed; however, the effective comparator for RAPN in this setting has yet to been defined. Bearing in mind current data that demonstrate RAPN to be a preferable minimally invasive PN technique compared with its standard laparoscopic counterparts, the real competitor for RAPN seems to be open surgery. This point was recently also reflected by Mottrie et al. LPN, as a challenging procedure with a long learning curve, limited diffusion and prevalent application in less complex cases, cannot be considered an attractive comparator for RAPN. During the last 8 years, RAPN has become a promising technique which can overcome the technical difficulties of LPN. Three-dimensional vision, ‘endowrist’ technology, and optical magnification allow excellent vision of the operative field and optimum tissue dissection. These technical characteristics help surgeons to minimize ischaemia-time and facilitate accurate tumour excision. Intra-operative ultrasonography, contrast-enhanced sonography, and photodynamic diagnostics can further improve this procedure. It was already shown that the availability of robotic technology is associated with increased use of PN, and, hence, broader diffusion in routine clinical practice may also provide the possibility to outperform results of open PN, even in more complex cases, and will make minimally invasive PN possible and available for more surgeons and patients. Today, the spread of RAPN is only limited by its availability and the associated financial burden. Hence, LPN will currently be considered a cheaper alternative to RAPN in centres with laparoscopic experience and in those which lack the availability of the robot.

Finally, the study from the Cleveland group and the series by Jain et al. provide some valuable support to the feasibility and safety of repeat RAPN and demonstrate that previously performed PN is not a contraindication for RAPN.

 

Sabine Brookman-May1, Andrea Minervini2, Alessandro Volpe3, Vincenzo Ficarra4, Maciej Salagierski5, Martin Marszalek6,7, Marco Roscigno8, Bülent Akdogan9, Alkuin Vandromme10, Hans Langenhuijsen11, Oscar Rodriguez-Faba12, and Steven Joniau13 for the Renal Cancer Working Group of the Young Academic Urologists (YAU) Working Party of the European Association of Urology (EAU)

1Department of Urology, Ludwig-Maximilians-University, Campus Grosshadern, Munich, Germany, 2Department of Urology, University of Florence, Florence, 3Department of
Urology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, 4Department of Oncological and Surgical Sciences, Urologic Unit, University of Padua, Padua,
Italy, 5Department of Urology, Medical University of Łódź, Łódź, Poland, 6Department of Urology and Andrology, Donauspital, Vienna, and 7Department of Urology, Graz Medical University, Graz, Austria, 8Department of Urology, AO Papa Giovanni XXIII, Bergamo, Italy, 9Department of Urology, Hacettepe University, School of Medicine, Ankara, Turkey, 10Klinik für Urologie und Uroonkologie, Klinikum Braunschweig, Germany, 11Laparoscopy, Robotics and Endourology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, 12Uro-oncology Unit, Fundacio Puigvert, Barcelona, Spain, and 13Department of Urology, University Hospitals Leuven, Leuven, Belgium

 

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