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Article of the Week: Partial versus Radical Nephrectomy for T1 renal tumour

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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 Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Marios Hadjipavlou, discussing his paper. 

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

Partial versus Radical Nephrectomy for T1 renal tumours: An analysis from the British Association of Urological Surgeons Nephrectomy Audit

Marios Hadjipavlou, Fahd Khan, Sarah Fowler*, Adrian Joyce†, Francis X. Keeley‡, Seshadri Sriprasad and on behalf of BAUS Sections of Endourology and Oncology

 

Department of Urology, Darent Valley Hospital, Dartford Kent, *British Association of Urological Surgeons, London, †Department of Urology, St James’s University Hospital, Leeds, and ‡Bristol Urological Institute, Southmead Hospital, Bristol, UK

 

Read the full article
OBJECTIVES

To analyse and compare data from the British Association of Urological Surgeons Nephrectomy Audit for perioperative outcomes of partial (PN) and radical nephrectomy (RN) for T1 renal tumours.

PATIENTS AND METHODS

UK consultants were invited to submit data on all patients undergoing nephrectomy between 1 January and 31 December 2012 to a nationally established database using a standard pro forma. Analysis was made on patient demographics, operative technique, and perioperative data/outcome between PN and RN for T1 tumours.

RESULTS

Overall, data from 6 042 nephrectomies were reported of which 1 768 were performed for T1 renal tumours. Of these, 1 082 (61.2%) were RNs and 686 (38.8%) were PNs. The mean age of patients undergoing PN was lower (PN 59 years vs RN 64 years; P < 0.001) and so was the WHO performance score (PN 0.4 vs RN 0.7; P < 0.001). PN for the treatment of T1a tumours (≤4 cm) accounted for 55.6% of procedures, of which 43.9% were performed using a minimally invasive technique. For T1b tumours (4–7 cm), 18.9% of patients underwent PN, in 33.3% of which a minimally invasive technique was adopted. The vast majority of RNs for T1 tumours were performed using a minimally invasive technique (90.3%). Of the laparoscopic PNs, 30.5% were robot-assisted. There was no significant difference in overall intraoperative complications between the RN and PN groups (4% vs 4.3%; P = 0.79). However, PN accounted for a higher overall postoperative complications rate (RN 11.3% vs PN 17.6%; P < 0.001). RN was associated with a markedly reduced risk of severe surgical complications (Clavien Dindo classification grade ≥3) compared with PN even after adjusting for technique (odds ratio 0.30; P = 0.002). Operation time between RN and PN was comparable (141 vs 145 min; P = 0.25). Blood loss was less in the RN group (mean for RN 165 vs PN 323 mL; P < 0.001); however, transfusion rates were similar (3.2% vs 2.6%; P = 0.47). RN was associated with a shorter length of stay (median 4 vs 5 days; P < 0.001). A direct comparison between robot-assisted and laparoscopic PN showed no significant differences in operation time, blood loss, warm ischaemia time, and intraoperative and postoperative complications.

CONCLUSIONS

PN was the method of choice for treatment of T1a tumours whereas RN was preferred for T1b tumours. Minimally invasive techniques have been widely adopted for RN but not for PN. Despite the advances in surgical technique, a substantial risk of postoperative complications remains with PN.

Editorial: Minimally invasive surgery or nephron preservation for small renal tumours?

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In the present issue of BJUI, there is an important study by Hadjipavlou et al. [1], summarizing radical (RN) and partial nephrectomy (PN) practice in the UK in 2012. Specifically, the authors reported the outcomes of ~1 800 patients undergoing either RN or PN for clinical T1 renal masses. Approximately 55% of the patients with cT1a tumours underwent PN, of whom 44% underwent minimally invasive PN. Conversely, in the cohort of patients with cT1b tumours, only ~19% received PN, of whom 33% underwent a minimally invasive procedure. Notably, whereas operating time, transfusion rate and the risk of intraoperative complications was similar for RN and PN, postoperative complications were approximately three times more common in patients who underwent PN, after adjusting for covariates. A sub-analysis comparing robot-assisted and laparoscopic PN failed to show any difference in peri-operative outcomes [1].

The study is important for several reasons. Firstly, it shows a fairly high adoption of PN for cT1a tumours. Although PN is recommended as the standard treatment for small renal masses [2], population-based studies have shown that there has been limited adoption of PN outside referral centres [3, 4], especially in the USA. Conversely, the present data from UK show more encouraging results, maximizing the benefit of nephron preservation; however, although PN might be more challenging in cT1b tumours and the available evidence in favour of PN in such a setting is less compelling, the adoption of PN was lower in such tumours. Efforts should be made to popularize such an approach whenever feasible.

Secondly, the study showed that a minority of the PN procedures were performed with a minimally invasive approach. Although we can agree that nephron preservation is more important than a minimally invasive approach in the long term for most patients, an increasing number of publications and growing clinical experience suggest that laparoscopic, and, above all, robot-assisted PN could represent the ideal solution. Although the number of minimally invasive PNs should increase with increased diffusion of DaVinci platforms, major efforts should be made to expand the number of patients in whom the morbidity of the traditional open PN approach can be avoided. In this context, regionalization of care for PN, as for other major oncological procedures, could be an excellent solution.

Thirdly, the significant rise in the risk of postoperative complications observed after PN could allow better selection of patients to undergo either PN or RN. For example, where surgery is indicated, frail comorbid patients, in whom the risk of perioperative complications should be minimized and who would benefit less from nephron preservation, could be better treated by laparoscopic RN or, probably, robot-assisted PN as performed by very experienced surgeons.

Finally, the study failed to show major differences between laparoscopic and robot-assisted PN. Although this finding is in line with data from systematic reviews of the literature [5], the present data from a large cohort of surgeons are more solid. The lack of data on patient selection, previous laparoscopic and robot-assisted surgery, annual surgical volume and tumour characteristics according to nephrometry scores, however, does not allow us to draw definitive conclusions on the issue. In our opinion, robot-assisted surgery might offer major significant benefits during PN in terms of quicker and more accurate tumour dissection, improved renorrhaphy with consequent shorter ischaemia time, lower risk of complications and a shorter learning curve as compared with pure laparoscopic PN.

Unfortunately, no analysis stratified by centre and/or surgeon volume was provided in the present paper. As with other major surgical procedures, some studies suggest that case volume may have a major impact on outcome [6]. It would have been interesting to see such a relationship analysed in the present cohort involving almost 300 surgeons from more than 100 institutions. Despite the large number of cases analysed, however, it is likely that these data depict the outcomes of RN and PN in a low-volume setting (an average of approximately six cases per year in total).

Finally, alternative approaches such as percutaneous or laparoscopic cryoablation are gaining popularity for the treatment of small renal masses in selected cases [2]. Although long-term oncological outcomes of such procedures are lacking, the available evidence suggests good short-term efficacy and safety for cryoablation in patients with small renal masses. The presence of data on such treatments to compare with the surgery results reported in the present cohort would also have been of interest.

Read the full article
Giacomo Novara, and Alexander Mottrie†‡

 

Department of Surgery, Oncology, and Gastroenterology, Urology Clinic, University of Padua, Padua, Italy, †Department of Urology, Onze-Lieve-Vrouw Hospital and ‡OLV Vattikuti Robotic Surgery Institute, Aalst, Belgium

 

References

 

1 Hadjipavlou M, Khan F, Fowler S, Joyce A, Keeley FX, Sriprasad S on behalf of BAUS Sections of Endourology & Oncology. Partial versus radical nephrectomy for T1 renal tumours: an analysis from the british association of urological surgeons nephrectomy audit. BJU Int 2015; 117:62–71
2 Ljungberg B, Bensalah K, Canfield S et al. EAU Guidelines on Renal Cell Carcinoma: 2014 Update. Eur Urol 2015; 67: 913–24

 

3 Sun M, Becker A, Tian Z et al. Management of localized kidney cancer: calculating cancer-specific mortality and competing risks of death for surgery and nonsurgical management. Eur Urol 2014; 65: 235–41

 

4 Fedeli U, Novara G, Alba N, Ficarra V, Artibani W, Spolaore P. Trends from 1999 to 2007 in the surgical treatments of kidney cancer in Europe: data from the Veneto Region, Italy. BJU Int 2010; 105: 1255–9

 

5 Aboumarzouk OM, Stein RJ, Eyraud R et al. Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol 2012; 62: 1023–33

 

6 Peyronnet B, Couapel JP, Patard JJ, Bensalah K. Relationship between surgical volume and outcomes in nephron-sparing surgery. Curr Opin Urol 2014; 24: 453–8

 

Video: T1 renal tumours: Partial versus Radical Nephrectomy

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Partial versus Radical Nephrectomy for T1 renal tumours: An analysis from the British Association of Urological Surgeons Nephrectomy Audit

Marios Hadjipavlou, Fahd Khan, Sarah Fowler*, Adrian Joyce†, Francis X. Keeley‡, Seshadri Sriprasad and on behalf of BAUS Sections of Endourology and Oncology

 

Department of Urology, Darent Valley Hospital, Dartford Kent, *British Association of Urological Surgeons, London, †Department of Urology, St James’s University Hospital, Leeds, and ‡Bristol Urological Institute, Southmead Hospital, Bristol, UK

 

Read the full article
OBJECTIVES

To analyse and compare data from the British Association of Urological Surgeons Nephrectomy Audit for perioperative outcomes of partial (PN) and radical nephrectomy (RN) for T1 renal tumours.

PATIENTS AND METHODS

UK consultants were invited to submit data on all patients undergoing nephrectomy between 1 January and 31 December 2012 to a nationally established database using a standard pro forma. Analysis was made on patient demographics, operative technique, and perioperative data/outcome between PN and RN for T1 tumours.

RESULTS

Overall, data from 6 042 nephrectomies were reported of which 1 768 were performed for T1 renal tumours. Of these, 1 082 (61.2%) were RNs and 686 (38.8%) were PNs. The mean age of patients undergoing PN was lower (PN 59 years vs RN 64 years; P < 0.001) and so was the WHO performance score (PN 0.4 vs RN 0.7; P < 0.001). PN for the treatment of T1a tumours (≤4 cm) accounted for 55.6% of procedures, of which 43.9% were performed using a minimally invasive technique. For T1b tumours (4–7 cm), 18.9% of patients underwent PN, in 33.3% of which a minimally invasive technique was adopted. The vast majority of RNs for T1 tumours were performed using a minimally invasive technique (90.3%). Of the laparoscopic PNs, 30.5% were robot-assisted. There was no significant difference in overall intraoperative complications between the RN and PN groups (4% vs 4.3%; P = 0.79). However, PN accounted for a higher overall postoperative complications rate (RN 11.3% vs PN 17.6%; P < 0.001). RN was associated with a markedly reduced risk of severe surgical complications (Clavien Dindo classification grade ≥3) compared with PN even after adjusting for technique (odds ratio 0.30; P = 0.002). Operation time between RN and PN was comparable (141 vs 145 min; P = 0.25). Blood loss was less in the RN group (mean for RN 165 vs PN 323 mL; P < 0.001); however, transfusion rates were similar (3.2% vs 2.6%; P = 0.47). RN was associated with a shorter length of stay (median 4 vs 5 days; P < 0.001). A direct comparison between robot-assisted and laparoscopic PN showed no significant differences in operation time, blood loss, warm ischaemia time, and intraoperative and postoperative complications.

CONCLUSIONS

PN was the method of choice for treatment of T1a tumours whereas RN was preferred for T1b tumours. Minimally invasive techniques have been widely adopted for RN but not for PN. Despite the advances in surgical technique, a substantial risk of postoperative complications remains with PN.

Article of the Week: Frozen Section During Partial Nephrectomy: Does it Predict Positive Margins?

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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.

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

Frozen Section During Partial Nephrectomy: Does it Predict Positive Margins?

Jennifer Gordetsky, Michael A. Gorin*, Joe Canner†, Mark W. Ball*, Phillip M. Pierorazio*, Mohamad E. Allaf* and Jonathan I. Epstein*

 

‡Departments of Pathology and Urology, The University of Alabama, Birmingham, AL , *Department of Urology, †Department of Surgery, Center for Surgical Trials and Outcomes Research, and ‡Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD, USA

 

Read the full article
OBJECTIVE

To investigate the clinical utility of frozen section (FS) analysis performed during partial nephrectomy (PN) and its influence on intra-operative management.

PATIENTS AND METHODS

We performed a retrospective analysis of consecutive PN cases from 2010 to 2013. We evaluated the concordance between the intra-operative FS diagnosis and the FS control diagnosis, a postoperative quality assurance measure performed on all FS diagnoses after formalin fixation of the tissue. We also evaluated the concordance between the intra-operative FS diagnosis and the final specimen margin. Operating reports were reviewed for change in intra-operative management for cases with a positive or atypia FS diagnosis, or if the mass was sent for FS.

RESULTS

A total of 576 intra-operative FSs were performed in 351 cases to assess the PN tumour bed margin, 19 (5.4%) of which also had a mass sent for FS to assess the tumour type. The concordance rate between the FS diagnosis and the FS control diagnosis was 98.3%. There were 30 (8.5%) final positive specimen margins, of which four (13.3%) were classified as atypia, 17 (56.7%) as negative and nine (30%) as positive on FS diagnosis. Intra-operative management was influenced in six of nine cases with a positive FS diagnosis and in one of nine cases with an FS diagnosis of atypia.

CONCLUSIONS

The relatively high false-negative rate, controversy over the prognosis of a positive margin, and inconsistency in influencing intra-operative management are arguments against the routine use of FS in PN cases.

Read more articles of the week

Editorial: Frozen section during partial nephrectomy: an unreliable test that changes nothing

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A core goal of oncological surgery is complete removal of the neoplastic mass. Conventional wisdom with regards to partial nephrectomy (PN) is that a minimal tumour-free margin is sufficient to achieve adequate cancer clearance, minimises loss of normal renal parenchyma and avoids local tumour recurrence [1]. Does this maximisation of nephron preservation and reported positive surgical margin rates after PN ranging from 0% to 7% [2] make intraoperative frozen sections a prerequisite? The results of the paper by Gordetsky et al. [3] in this month’s issue of BJU International suggest that frozen section results from the tumour bed of patients undergoing a PN may be both unreliable and result in subsequent inconsistent management decisions by the operating surgeon.

A recent survey of 197 American urologists revealed that up to 69% (‘always’ or ‘sometimes’) undertake a frozen section during PN [4]. In view of such high penetrance of this test with a resulting high workload for the uro-pathologist, it is critical that the test is reliable and the results are positively and consistently acted upon by the operating urologist.

Gordetsky et al. [3] present interesting data from an expert uro-pathology service, on a consecutive cohort of patients undergoing PN. Reassuringly the pathologist’s skill at making the correct call on the frozen-section specimen was extremely high with a 98% concordance between the actual frozen section and the subsequently created formalin-fixed paraffin-embedded tissue block from the very same piece of tissue. However, despite this high level of accuracy, the sensitivity of the tumour bed frozen section in predicting the actual presence of a positive surgical margin in the resected tumour was only 30% (in other words, of all the patients who actually had positive surgical margins only 30% were identified by frozen section analysis of the tumour bed). As tumour bed biopsies only represent a small fraction of the resection margin this is perhaps unsurprising.

The second issue addressed by Gordetsky et al. [3] is the matter of an inconsistent response of the surgeon to a positive frozen section. In five cases no action was taken, in three cases the tumour bed was re-resected and in a single case a subsequent radical nephrectomy was performed. These results can be compared with those of Sidana et al. [4], where there was a similar inconsistency of management strategies. This inconsistency can be explained by the controversy surrounding the oncological importance of a positive surgical. There is evidence that a positive margin may be associated with an increased risk of recurrence; however, it does not appear to infer a poorer long-term oncological outcome for the patient [5]. It is intriguing that at the time of a completion nephrectomy following a positive surgical margin, residual malignant cells were not found in any of the patients who underwent a re-resection or nephrectomy in this and other studies [3, 6]. It should, however, be noted that published series of conservative management of positive margins are few with only medium-term follow-up. As we know that the natural history of the small renal mass is one of slow growth, any microscopic residual disease may take several years to become clinically apparent and these studies are therefore underpowered.

We think there are several practical arguments against routine use of frozen section. Whilst waiting for the frozen section result some surgeons have been known to keep the kidney ischaemic (16%) resulting in consequent loss of renal function [4]. To avoid this many urologists will undertake the renorrhaphy whilst waiting for the result, a practice becoming increasingly more common with the move towards laparoscopic and robot-assisted PN, where tumour extraction is usually the final step. This practice inevitably influences the subsequent enthusiasm of the surgeon to go back and perform a re-resection and re-do renorrhaphy. It is known that the surgeons’ gross interpretation of the surgical margin approaches the sensitivity of the permanent section and has low false-negative rates, apparently superior to tumour bed frozen section [7]. Routine cautery of the resection bed may also provide an additional safety margin and render any microscopic positive margin clinically insignificant.

It is our opinion that this work by Gordetsky et al. [3] adds credence to the stand that there is no need for a routine tumour bed frozen section in PN and that careful examination of the resected tumour with selected frozen section analysis of suspicious areas is a safe strategy, saves time and provides adequate information for intraoperative decision making.

Read the full article
Grant D. Stewart, *† and Grenville Oades, ‡

 

*Clinical Senior Lecturer, Edinburgh Urological Cancer Group, University of Edinburgh,†Honorary Consultant in Urological Surgery, Department of Urology, NHS Lothian, Edinburgh, and ‡Consultant Urological Surgeon, Department of Urology, NHS Greater Glasgow and Clyde, Glasgow, UK

 

References

 

1 Sutherland SE, Resnick MI, Maclennan GT, Goldman HB. Does the size of the surgical margin in partial nephrectomy for renal cell cancer really matter? J Urol 2002; 167: 61–4

 

2 Marszalek M, Carini M , Chlosta P et al. Positive surgical margins after nephron-sparing surgery. Eur Urol 2012; 61: 757–63

 

3 Gordetsky J, Gorin M, Canner J et al. Frozen section during partial nephrectomy: does it predict positive margins? BJU Int 2015; 116: 868–72

 

4 Sidana A, Donovan JF, Gaitonde K. Surgeons’ preferences and practice patterns regarding intraoperative frozen section during partial nephrectomy. Urol Oncol 2014; 32: 864–8

 

5 Bensalah K, Pantuck AJ, Rioux-Leclercq N et al. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol 2010; 57: 466–71

 

6 Raz O, Mendlovic S, Shilo Y et al. Positive surgical margins with renal cell carcinoma have a limited influence on long-term oncological outcomes of nephron sparing surgery. Urology 2010; 75: 277–80

 

7 Timsit MO, Bazin JP, Thiounn N et al. Prospective study of safety margins in partial nephrectomy: intraoperative assessment and contribution of frozen section analysis. Urology 2006; 67: 923–6

 

Clever surgeons and challenging study endpoints

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CaptureIntraoperative in vivo tracking of a periprostatic nerve with multiphoton microscopy in rat model.

In the last 6 months, the BJUI editorial team has evaluated an average of 59 urological oncology papers per month with an average acceptance rate of 16%. We receive additional papers for our ‘Translational Science’ section. Studies with high-quality methods are given the highest priority. Other papers compete well if they are highly applicable to clinical practice (i.e. comparative, multicentre, multi-surgeon design) and/or show us new ideas in surgical technique, re-designed study endpoints, or explore new sources of data. For translational science, the best candidates are studies that look at new diagnostic tests in humans and beyond simple immunostaining techniques. We want to evaluate biomarkers likely to be validated and translated into a clinical test. Clinical impact will be even higher if a biomarker is linked to a therapy outcome rather than just a risk estimate. We want our papers to guide us to better outcomes for our patients, hopefully control healthcare costs, and, yes, be well-cited in the literature.

Our review process is tough but fair, and we congratulate and highlight three authorship groups for acceptance into this month’s issue of BJUI. The theme of ‘clever surgeons and challenging study endpoints’ is well illustrated by all three groups. Zargar et al. [1] report on an exclusive database of high-volume minimally invasive surgeons who have tackled the partial nephrectomy option for small renal masses. The comparison is simple in concept and retrospective in design, but what they have done is to significantly increase the outcome measures into a ‘trifecta’ concept in perioperative outcomes (previously reported) with an even more stringent ‘optimal outcome’ endpoint that includes renal function preservation. With a database of 1185 robotic and 646 laparoscopic cases, the robotic procedures showed superior trifecta results (70% vs 33%), complication rates (14.8% vs 20.9%), positive surgical margin rates (3.2% vs 9.7%), and warm ischaemia time (18 vs 26 min). The optimal outcome endpoint included a minimum 90% estimated GFR (eGFR) preservation and no chronic kidney disease upstaging. Only the robotic cohort had sufficient data available and the rate was 38.5%. The latter figure is an interesting challenge, as defining such a high threshold for success challenges surgical technique and allows more room to identify incremental advancement. This may be the largest study of its kind, but non-randomised and with limitations discussed in peer review such as the learning curve influence, use of eGFR as an endpoint with two kidneys, and incomplete data. The definitions used are of interest and the field could use some uniformity moving forward in measuring perioperative and long-term benchmarks of quality.

Durand et al. [2] give us a glimpse into the future of surgery, a science fiction world of prostate surgery where nerves and prostatic glands can be colour coded and seen at a microscopic level in real time. The pictures stand for themselves, especially Fig. 1. If such imaging can be integrated into technique decisions, and perhaps future instrument designs, then perhaps we will have a whole new wave of studies possible on linking surgical technique to improved functional and oncological outcomes after radical prostatectomy. The paper has a nice depth in detail, methods, results, as well as narratives in solving technical problems with novel technology.

This issue’s ‘Article of the Month’ by Gavin et al. [3] is a different look at the question of morbidity after localised prostate cancer treatments, specific to long-term care at >2 years from treatment. The database is from a cancer registry and they have an impressive 54% response rate from a population that is 2–18 years from diagnosis. Rather than Likert-like scales of symptom severity, they simply look at ‘current’ vs ‘ever had’ symptoms and look at the total burden including multiple/overlapping symptoms. Although this may not be as robust and validated as the Expanded Prostate Cancer Index Composite (EPIC) instrument, the simple phrasing of ‘current’ vs ‘ever had’ is probably capturing a very high proportion of symptoms rather than dismissing them if minor or in the past. Again, we see more erectile dysfunction after radical prostatectomy and radiation with hormonal therapy, and more bowel symptoms after radiation therapy. Hormone therapy patients have hot flashes and fatigue, and watchful-waiting patients have some advantages but are certainly not free of symptoms. The burden of symptoms is interesting, nine of 10 reported at least one of seven key symptoms at some point and three of four are current. Therefore, as the authors indicate, ≈75% of prostate cancer survivors will have ongoing symptoms needing follow-up care. This is a significant database resource adding to our understanding of long-term outcomes of patients with prostate cancer and supporting the significance of the Durand et al. [2] study that may show the way forward towards reducing such burdens of disease treatment.

 

References

1 Zargar H, Al laf ME, 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

 

2 Durand M, Jain M, Aggarwal A et al. Real-time in vivo periprostatic nerve tracking using multiphoton microscopy in a rat survival surgery model: a promising pre-clinical study for enhanced nerve-sparing surgery. BJU Int 2015; 478–86

 

3 Gavin AT, Drummond FJ, Donnelly C, O’Leary E, Sharp L, Kinnear HR. Patient-reported ‘ever had’ and ‘current’ long-term physical symptoms after prostate cancer treatments. BJU Int 2015; 397–406

John W. Davis, MD
Associate Editor, BJUI

Highlights from #BAUS15

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#BAUS15 started to gain momentum from as early as the 26th June 2014 and by the time we entered the Manchester Central Convention Complex well over 100 tweets had been made. Of course it wasn’t just Twitter that started early with a group of keen urologists cycling 210 miles to conference in order to raise money for The Urology Foundation.

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Monday 15th June 2015

By the time the cyclists arrived conference was well under way with the andrology, FNUU and academic section meetings taking place on Monday morning:

  • The BJU International Prize for the Best Academic Paper was awarded to Richard Bryant from the University of Oxford for his work on epithelial-to-mesenchymal transition changes found within the extraprostatic extension component of locally invasive prostate cancers.
  • Donna Daly from the University of Sheffield received the BJUI John Blandy prize for her work on Botox, demonstrating reductions in afferent bladder signaling and urothelial ATP release.

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  • Professor Reisman’s talk on ‘Porn, Paint and Piercing’ as expected drew in the crowds and due to a staggering 44% complication rate with genital piercings it is important for us to try to manage these without necessarily removing the offending article as this will only serve to prevent those in need from seeking medical attention.
  • With the worsening worldwide catastrophe of antibiotic resistance, the cycling of antibiotics for prevention of recurrent UTIs is no longer recommended. Instead, Tharani Nitkunan provided convincing evidence for the use of probiotics and D-Mannose.

The afternoon was dominated by the joint oncology and academic session with Professor Noel Clarke presenting the current data from the STAMPEDE trial. Zolendronic acid conferred no survival benefit over hormones alone and consequently has been removed from the trial (stampede 1). However, Docetaxal plus hormones has shown benefit, demonstrated significantly in M1 patients with disease-free survival of 65 months vs. 43 months on hormones alone (Hazard ratio 0.73) (stampede 2). This means that the control arm of M1 patients who are fit for chemotherapy will now need to be started on this treatment as the trial continues to recruit in enzalutamide, abiraterone and metformin arms.

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The evening was rounded off with the annual BAUS football tournament won this year by team Manchester (obviously a rigged competition!), whilst some donned the

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lycra and set out for a competition at the National Cycle Centre. For those of us not quite so energetic, it was fantastic to catch up with old friends at the welcome drinks reception.

 

Tuesday 16th June 2015

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Tuesday kicked off bright and early with Professor John Kelly presenting results from the BOXIT clinical trial, which has shown some benefit over standard treatment of non-muscle invasive bladder cancer, but with significant cardiovascular toxicity.

The new NICE bladder cancer guidelines were presented with concerns voiced by Professor Marek Babjuk over discharging low-risk bladder cancer at 12 months given a quoted 30-50% five-year recurrence risk. Accurate risk stratification, it would seem, is going to be key.

The President’s address followed along with the presentation of the St. Peter’s medal for notable contribution to the advancement of urology, which was presented to Pat Malone from Southampton General Hospital. Other medal winners included Adrian Joyce who received the BAUS Gold Medal, and the St. Paul’s medal went to Mark Soloway.

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A plethora of other sessions ensued but with the help of the new ‘native’ BAUS app my programme was already conveniently arranged in advance:

  •     ‘Heartsink Conditions’ included pelvic and testicular pain and a fascinating talk by Dr Gareth Greenslade highlighted the importance of early and motivational referral to pain management services once no cause has been established and our treatments have been exhausted. The patient’s recovery will only start once we have said no to further tests: ‘Fix the thinking’
  • Poster sessions are now presented as ‘e-posters’, abolishing the need to fiddle with those little pieces of Velcro and allowing for an interactive review of the posters.

 

Photo 22-06-2015 22 36 07Pravisha Ravindra from Nottingham demonstrated that compliance with periodic imaging of patients with asymptomatic small renal calculi (n=147) in primary care is poor, and indeed, these patients may be better managed with symptomatic imaging and re-referral as no patients required intervention based on radiograph changes alone.

Archana Fernando from Guy’s presented a prospective study demonstrating the value of CTPET in the diagnosis of malignancy in  patients with retroperitoneal fibrosis (n=35), as well as demonstrating that those with positive PET are twice as likely to respond to steroids.

 

Wednesday 17th June 2015

Another new addition to the programme this year was the Section of Endourology ‘as live surgery’ sessions. This was extremely well received and allowed delegates to benefit from observing operating sessions from experts in the field whilst removing the stressful environment and potential for risk to patient associated with live surgery. This also meant that the surgeon was present in the room to answer questions and talk through various steps of the operation allowing for a truly interactive session.
Wednesday saw multiple international speakers dominating the Exchange Auditorium:

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  • The BJU International guest lecture was given by Professor Hendrik Van Poppel: a heartfelt presentation describing what he believes to be the superiority of surgery over radiotherapy for high-risk localised prostate cancer.
  • The Urology Foundation presented the Research Scholar Medal to Ashwin Sachdeva from Freeman Hospital, Newcastle for his work on the ‘Role of mitochondrial DNA mutations in prostate carcinogenesis’. This was followed by an inspiring guest lecture by Inderbir Gill on ‘Robotic Urologic Oncology: the best is yet to come’ with the tag line ‘the only thing that should be open in 2015 is our minds’
  • Robotic Surgery in UK Urology: Clinical & Commissioning Priorities was a real highlight in the programme with talks from Jim Adshead and Professor Jens-Uwe Stolzenburg focussing on the fact that only 40% of T1a tumours in the UK were treated with partial (as opposed to radical) nephrectomy, and that the robot really is the ‘game-changer’ for this procedure. Inderbir Gill again took to the stage to stress that all current randomised trials into open vs. robotic cystectomy have used extracorporeal reconstruction and so do not reflect the true benefits of the robotic procedure as the dominant driver of complications is in the open reconstruction.

These lectures were heard by James Palmer, Clinical Director of Specialised Commissioning for NHS England who then discussed difficulties in making decisions to provide new technologies, controlling roll out and removing them if they show no benefit. Clinical commissioning policies are currently being drafted for robotic surgery in kidney and bladder cancer. This led to a lively debate with Professor Alan McNeill having the last word as he pointed out that what urologists spend on the robot to potentially cure cancer is a drop in the ocean compared with what the oncologists spend to palliate!

 

Thursday 18th June 2015

The BJU International session on evidence-based urology highlighted the need for high-quality evidence, especially in convincing commissioners to spend in a cash-strapped NHS. Professor Philipp Dahm presented a recent review in the Journal of Urology indicated that the quality of systematic reviews in four major urological journals was sub-standard. Assistant Professor Alessandro Volpe then reviewed the current evidence behind partial nephrectomy and different approaches to this procedure.

Another fantastic technology, which BAUS adopted this year, was the BOD-POD which allowed delegates to catch-up on sessions in the two main auditoria that they may have missed due to perhaps being in one of the 21 well designed teaching courses that were available this year. Many of these will soon be live on the BAUS website for members to view.

The IBUS and BAUS joint session included a lecture from Manoj Monga from The Cleveland Clinic, which led to the question being posed on Twitter: ‘Are you a duster or a basketer?’The audience was also advised to always stent a patient after using an access sheath unless the patient was pre-stented.

Photo 23-06-2015 20 28 55

 

The updates session is always valuable especially for those studying for the FRCS (Urol) exam with far too many headlines to completely cover:

  • Endourology: The SUSPEND trial published earlier this year was a large multi-centre RCT that showed no difference in terms of rates of spontaneous passage of ureteric stone, time to stone passage or analgesic use between placebo, tamsulosin and nifedipine. There was a hot debate on this: should we be waiting for the meta-analysis or should a trial of this size and design be enough to change practice?
  • Oncology-Prostate: The Klotz et al., paper showed active surveillance can avoid over treatment, with 98% prostate cancer survival at 10 years.
  • Oncology-Kidney: Ellimah Mensah’s team from Imperial College London (presented at BAUS earlier in the week) demonstrated that over a 14-year period there were a higher number of cardiovascular-related admissions to hospital in patients who have had T1 renal tumours resected than the general population, but no difference between those who have had partial or radical nephrectomy.
  • Oncology-Bladder: Arends’s team presented at EAU in March on the favourable results of hyperthermic mitomycin C vs. BCG in the treatment of intermediate- and high-risk bladder cancer.
  • Female and BPH: The BESIDE study has demonstrated increased efficacy with combination solifenacin and mirabegron.
  • Andrology: Currently recruiting in the UK is the MASTER RCT to evaluate synthetic sling vs. artificial sphincter in men with post-prostatectomy urinary incontinence.

 

Overall BAUS yet again put on a varied and enjoyable meeting. The atmosphere was fantastic and the organisers should be proud of the new additions in terms of allowing delegates to engage with new technologies, making for a memorable week. See you all in Liverpool!

 

Photo 18-06-2015 12 15 03

Rebecca Tregunna, Urological Trainee, West Midlands Deanery @rebeccatregunna

 

Dominic Hodgson, Consultant Urologist, Portsmouth @hodgson_dominic

 

Article of the Week: Renal Function is the same regardless of clamp technique 6 months after RAPN

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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.

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 Prof. Rha, discussing his paper. 

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

Renal Function is the same regardless of clamp technique 6 months after Robot-assisted Partial Nephrectomy: Analysis of Off-Clamp, Selective Arterial Clamp and Main Artery Clamp with minimum of 1 year follow-up.

Christos Komninos*‡, Tae Young Shin†, Patrick Tuliao*, Woong Kyu Han*, Byung Ha Chung*, Young Deuk Choi* and Koon Ho Rha* 

 

*Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, †Department of Urology, Chuncheon Sacred Hospital, Hallym Medical College, Chuncheon, Korea, and ‡Department of Urology, General Hospital of Nikaia ‘St. Panteleimon’, Athens, Greece
Read the full article
OBJECTIVE

To compare the renal functional outcomes, with >1 year of follow-up, of patients who underwent robot-assisted partial nephrectomy (RAPN) performed with different clamping techniques.

PATIENTS AND METHODS

The peri-operative data of patients undergoing RAPN performed with different clamping techniques were retrospectively analysed (group 1: off-clamp, n = 23; group 2: selective clamp, n = 25; group 3: main artery clamp, n = 114). The main outcome measures were postoperative serum creatinine level, estimated glomerular filtration rate (eGFR) and percentage change in eGFR, the data for which were collected at periodic intervals during the first 12 months and annually thereafter, in addition to late eGFR value. Only patients with >1 year of follow-up were included in the analysis.

RESULTS

The baseline characteristics of groups 2 and 3 were similar, while patients in group 1 had smaller sized tumours and lower tumour complexity. The median follow-up periods were 45 (group 1), 20 (group 2) and 47 (group 3) months. The median clamping times were 24.8 min in the main artery clamp and 18 min in the selective artery clamp groups. Group 2 had greater median blood loss volume (100 vs 500 vs 200 mL for groups 1, 2 and 3, respectively; P < 0.01) and a longer length of hospital stay (3 vs 4 vs 3 days for groups 1, 2 and 3, respectively; P = 0.02). No significant differences were found among the groups with regard to transfusion rates, positive surgical margin rates, complications, recurrence or mortality rates. Groups 1 and 2 had significantly less deterioration of postoperative renal function during the first 3 months after surgery (P = 0.04; percent change in eGFR −1.5, −2 and −8% for groups 1, 2 and 3, respectively), but this beneficial outcome was not observed after 6 months or for the latest eGFR measurement (P = 0.48; latest percent change in eGFR −3, −6 and −3.5% for groups 1, 2 and 3, respectively). In regression analysis, baseline eGFR, type of clamp procedure and tumour complexity score were predictive of normal renal function 7 days after surgery, while only baseline eGFR and age could predict it 1 year postoperatively.

CONCLUSIONS

Off-clamp and selective artery clamp techniques result in superior short-term renal functional outcomes compared with the main artery clamp approach; however, after the 6th postoperative month, there were no significant differences regarding the functional outcome among the above surgical techniques, as long as the warm ischaemia time was 20–30 min.

Read more articles of the week

Editorial: To clamp or not to clamp in robotic partial nephrectomy?

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The article by Komninos et al. [1], in this issue of the BJUI has looked into the importance of warm ischaemia techniques in robot-assisted partial nephrectomy (RAPN) on the deterioration in short- and longer-term renal function. A case series of 162 procedures undertaken by a single surgeon over a 7-year period was analysed. Within this cohort, 114 patients underwent main artery clamping, whilst 23 and 25 patients underwent off-clamp and selective artery clamping methods, respectively.

Segmental artery clamping and off-clamp techniques have been recently developed to minimize the warm ischaemia time (WIT), which, if prolonged, can result in loss of normal functioning parenchyma, potentially causing renal impairment [2]. This paper has correctly identified that many studies on RAPN within the literature have a limited 6-month follow-up regarding postoperative renal function, and the authors sought to evaluate this further. They have shown that significantly less deterioration in renal function over the first 3 months is seen in the off-clamp and selective artery clamp techniques compared with main artery clamping. Importantly, however, this reduction seems transient and was not seen at 6 months and 1 year after surgery.

The authors comment on the median clamping times used in the two separate clamping techniques, with 24.8 and 18 min in the main artery and selective artery clamping groups, respectively; however, no specific analysis was provided of the significance of these times on renal function outcome. Elsewhere Abreu et al. [3], have reported that ‘zero ischaemia time’, with no hilar clamping, preserves renal function with a median decrease of 0 mg/dL in creatinine and a 5 mL/min/1.73 m2 reduction in estimated GFR (eGFR) rate at hospital discharge in a robotic surgery series. Similarly, George et al. [4] have shown that, at 6 months, less renal injury is sustained, as demonstrated by eGFR, when an off-clamp laparoscopic technique was used compared with an on-clamp technique, and that WIT was a significant predictor of decreased eGFR in the postoperative period.

Warm ischaemia time is a topic of much debate in the literature and remains a controversial area of significant interest. As most predictors of eGFR, such as age, comorbidity and pre-existing renal function, are unmodifiable, the attractive challenge with WIT is that it is a surgically modifiable variable. Reassuringly, RAPN clamp time is typically shorter than in pure laparoscopic partial nephrectomy, and usually shorter than the generally accepted limit of 30 min that has been associated with good preservation of postoperative renal function [5]. More recently, Wiener et al. [6] were able to establish that WIT ≤ 22 min prevented a statistically significant decline in renal function at 6–12 months.

In light of this evidence, another technique of ‘early unclamping’ is being increasingly considered, especially in RPN, but several considerations, including increased blood loss and potential increased difficulty with the renorrhaphy, have limited its application [5]. The paper by Komninos et al. is supported by another study that analysed 95 consecutive RAPN cases, in which a variety of clamping techniques was used (artery and vein, artery alone and unclamp), showing that GFR and overall percentage decrease in GFR was similar for all three methods at a median follow-up of 6 months and suggesting that intermediate-term renal function outcome is irrespective of clamping technique [7].

Clearly there are limitations to the present study, including its non-randomized, retrospective nature and the low sample sizes of the off-clamp and selective artery groups and the authors have recognized this. The entire population also had a low body mass index and comorbidity status compared with many RAPN series. The off-clamp tumours were all relatively exophytic, significantly smaller than the other groups (1.7 vs 3.5 and 3.3 cm), and far less complex, with PADUA scores of 7 compared with 10 and 9. Despite this, the study has shown, with a respectable follow-up period, that although there is a significant initial deterioration in renal function with the main artery clamping technique at 3 months compared with the selective artery and off-clamp methods, there was no significant difference in renal deterioration between the three groups at 6 months and at 1 year.

It is also interesting to see that, even though patients in the main artery clamping group had larger and more complex tumours, inevitably resulting in a greater resected volume of normal-functioning nephrons, renal function deterioration was no different from the off-clamp group by 6 months. The authors have contributed to the evidence for main artery clamping in RPN, particularly in complex tumours in healthy younger patients with bilateral functioning renal units. Techniques to minimize warm ischaemia are likely to continue to have a role in higher risk and imperative indications for partial nephrectomy.

Read the full article
Buket N. Ertansel, Norbert Doeuk and Ben Challacombe

 

Guy’s & St Thomas’s Hospital, London, UK

 

References

 

1 Komninos C, Shin TY, Tuliao P et al. Renal Function is the same regardless of clamp technique 6 months after Robot-assisted Partial Nephrectomy: analysis of Off-Clamp, Selective Arterial Clamp and Main Artery Clamp with minimum of 1 year follow-up. BJU Int 2014; doi: 10.1111/bju.12975. [Epub ahead of print]

 

2 Thompson RH, Lane BR, Lohse CM et al. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol 2010; 58: 340–5

 

3 Abreu AL, Gill IS, Desai MM. Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours. BJU Int 2011; 108 (Pt 2): 948–54

 

4 George AK, Herati AS, Srinivasan AK et al. Perioperative outcomes of offclamp vs complete hilar control laparoscopic partial nephrectomy. BJU Int 2013; 111 (Pt B): E235–41

 

5 Cawley O, Roman A, Brown M, Challacombe B. Exploring the evidence for early unclamping during robot-assisted partial nephrectomy: is it worth the time and effort? BJU Int 2014; doi: 10.1111/bju.12836. [Epub ahead of print]

 

6 Wiener S, Kiziloz H, Dorin RP, Finnegan K, Shichman SS, Meraney A. Predictors of postoperative decline in estimated glomerular filtration rate in patients undergoing robotic partialnephrectomy. J Endourol 2014; 28: 807–13

 

7 Krane LS, Mufarrij PW, Manny TB, Hemal AK. Comparison of clamping technique in robotic partial nephrectomy: does unclamped partial nephrectomy improve perioperative outcomes and renal function? Can J Urol 2013; 20: 6662–7

 

 

Video: 6 months after RAPN – Renal Function is the same regardless of clamp technique

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Renal Function is the same regardless of clamp technique 6 months after Robot-assisted Partial Nephrectomy: Analysis of Off-Clamp, Selective Arterial Clamp and Main Artery Clamp with minimum of 1 year follow-up.

Christos Komninos*‡, Tae Young Shin†, Patrick Tuliao*, Woong Kyu Han*, Byung Ha Chung*, Young Deuk Choi* and Koon Ho Rha* 

 

*Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, †Department of Urology, Chuncheon Sacred Hospital, Hallym Medical College, Chuncheon, Korea, and ‡Department of Urology, General Hospital of Nikaia ‘St. Panteleimon’, Athens, Greece
Read the full article
OBJECTIVE

To compare the renal functional outcomes, with >1 year of follow-up, of patients who underwent robot-assisted partial nephrectomy (RAPN) performed with different clamping techniques.

PATIENTS AND METHODS

The peri-operative data of patients undergoing RAPN performed with different clamping techniques were retrospectively analysed (group 1: off-clamp, n = 23; group 2: selective clamp, n = 25; group 3: main artery clamp, n = 114). The main outcome measures were postoperative serum creatinine level, estimated glomerular filtration rate (eGFR) and percentage change in eGFR, the data for which were collected at periodic intervals during the first 12 months and annually thereafter, in addition to late eGFR value. Only patients with >1 year of follow-up were included in the analysis.

RESULTS

The baseline characteristics of groups 2 and 3 were similar, while patients in group 1 had smaller sized tumours and lower tumour complexity. The median follow-up periods were 45 (group 1), 20 (group 2) and 47 (group 3) months. The median clamping times were 24.8 min in the main artery clamp and 18 min in the selective artery clamp groups. Group 2 had greater median blood loss volume (100 vs 500 vs 200 mL for groups 1, 2 and 3, respectively; P < 0.01) and a longer length of hospital stay (3 vs 4 vs 3 days for groups 1, 2 and 3, respectively; P = 0.02). No significant differences were found among the groups with regard to transfusion rates, positive surgical margin rates, complications, recurrence or mortality rates. Groups 1 and 2 had significantly less deterioration of postoperative renal function during the first 3 months after surgery (P = 0.04; percent change in eGFR −1.5, −2 and −8% for groups 1, 2 and 3, respectively), but this beneficial outcome was not observed after 6 months or for the latest eGFR measurement (P = 0.48; latest percent change in eGFR −3, −6 and −3.5% for groups 1, 2 and 3, respectively). In regression analysis, baseline eGFR, type of clamp procedure and tumour complexity score were predictive of normal renal function 7 days after surgery, while only baseline eGFR and age could predict it 1 year postoperatively.

CONCLUSIONS

Off-clamp and selective artery clamp techniques result in superior short-term renal functional outcomes compared with the main artery clamp approach; however, after the 6th postoperative month, there were no significant differences regarding the functional outcome among the above surgical techniques, as long as the warm ischaemia time was 20–30 min.

Read more articles of the week
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