ABSTRACT: Study Type - Harm (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Radical nephrectomy for patients with metastatic renal cell carcinoma results in greater rates of morbidity than for those with less advanced disease. This study systematically characterizes complications associated with nephrectomy for metastatic RCC and identifies patient and disease characteristics that are associated with a greater risk of developing complications. Overall complications were relatively frequent, but major complications (grade 3 or greater) were rare. Increasing age and worsening performance status were associated with increased probability of complications. When complications were sustained, patients were less likely to receive systemic therapy in a timely fashion. These observations may influence the timing or patient selection for surgery or systemic therapy.
• To evaluate and identify factors predictive for morbidity after radical nephrectomy in patients with metastatic renal cell carcinoma (mRCC).
• We identified patients with mRCC who underwent nephrectomy at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1989 and 2009. • Postoperative complications were characterised using a modified version of the Clavien-Dindo classification system. • Patient and disease characteristics, including a previously validated MSKCC risk-stratification system using calcium, haemoglobin (Hb), lactate dehydrogenase, and Karnofsky Performance Status (KPS), were evaluated as predictors of postoperative complications using univariate and multivariable logistic regression models. • The area under the receiver operating characteristic curve (AUC) was calculated for each model to assess predictive accuracy and corrected for overfit using 10-fold cross validation.
• Over the study period, 195 patients with mRCC underwent nephrectomy; 53 (27%) developed grade ≥2 complications within 8 weeks of surgery. • Pulmonary, thromboembolic events and anaemia requiring transfusion were the most common types of complications after nephrectomy in the metastatic setting. • In univariate analysis, age, low albumin, low KPS, high corrected serum calcium, low serum Hb, and unfavourable MSKCC risk score were predictive of complications. • Patients who sustained postoperative complications were less likely to receive systemic therapy within 56 days (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.12-0.86; P= 0.024). • A multivariable model containing KPS (OR 14.5; 95%CI 4.34-48.6; P < 0.001) and age (OR 1.04; 95%CI 1.01-1.08; P= 0.014) showed the greatest predictive accuracy (corrected AUC 0.72; 95%CI 0.63-0.80) for postoperative complications.
• Postoperative complications after radical nephrectomy in the setting of mRCC are common and occur frequently in older patients and those with worse KPS. • These complications are important because they may delay or deny receipt of subsequent systemic therapy.
BJU International 05/2012; 110(9):1276-82. · 2.84 Impact Factor
ABSTRACT: We compared renal function and oncologic outcomes of parenchymal sparing ureteral resection with radical nephroureterectomy for the treatment of upper tract urothelial carcinoma confined to the ureter.
Review of a large institutional database identified 367 patients treated for primary upper tract urothelial carcinoma with radical nephroureterectomy or parenchymal sparing ureteral resection from 1994 to 2009. Patients with known renal pelvis tumors, muscle invasive urothelial carcinoma, prior cystectomy, contralateral upper tract urothelial carcinoma, metastatic disease or chemotherapy were excluded, leaving 120 patients for analysis. Estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease equation. Recurrence-free, cancer specific and overall survival were estimated using Kaplan-Meier analysis.
Radical nephroureterectomy was performed in 87 patients and parenchymal sparing ureteral resection in 33. Median age at surgery was 73 years in the radical nephroureterectomy group (IQR 64-76) vs 70 years (IQR 59-77) in the parenchymal sparing ureteral resection group (p = 0.5). The radical nephroureterectomy and parenchymal sparing ureteral resection cohorts had several disparate clinicopathological variables including preoperative hydronephrosis (80% vs 45%, p = 0.0006), stage (pT3 or greater 26% vs 9%, p = 0.01) and baseline estimated glomerular filtration rate (51 vs 63 ml/minute/1.73 m(2), p = 0.009). Patients who underwent radical nephroureterectomy experienced a significantly greater decrease in estimated glomerular filtration rate after surgery (median -7 vs 0 ml/minute/1.73 m(2), p <0.001). Median followup was 4.2 years. Of the patients 79 experienced cancer recurrence and 44 died (28 of upper tract urothelial carcinoma). There were no obvious differences in the rates of recurrence, cancer specific death or overall death by procedure type. However, due to the limited number of events we cannot exclude the possibility that there are large differences in oncologic outcomes by procedure type.
Parenchymal sparing ureteral resection is associated with superior postoperative renal function. However, the impact on cancer control cannot be determined conclusively due to the small sample size and putative selection bias.
The Journal of urology 12/2011; 187(2):429-34. · 4.02 Impact Factor
ABSTRACT: To create a preoperative multivariable model to identify patients at risk of muscle-invasive (pT2+) upper tract urothelial carcinoma (UTUC) and/or non-organ confined (pT3+ or N+) UTUC (NOC-UTUC) who potentially could benefit from radical nephroureterectomy (RNU), neoadjuvant chemotherapy and/or an extended lymph node dissection.
We retrospectively analysed data from 324 consecutive patients treated with RNU between 1995 and 2008 at a tertiary cancer centre. Patients with muscle-invasive bladder cancer were excluded, resulting in 274 patients for analysis. Logistic regression models were used to predict pT2+ and NOC-UTUC. Pre-specified predictors included local invasion (i.e. parenchymal, renal sinus fat, or periureteric) on imaging, hydronephrosis on imaging, high-grade tumours on ureteroscopy, and tumour location on ureteroscopy. Predictive accuracy was measured by the area under the curve (AUC).
The median follow-up for patients without disease recurrence or death was 4.2 years. Overall, 49% of the patients had pT2+, and 30% had NOC-UTUC at the time of RNU. In the multivariable analysis, only local invasion on imaging and ureteroscopy high grade were significantly associated with pathological stage. AUC to predict pT2+ and NOC-UTUC were 0.71 and 0.70, respectively.
We designed a preoperative prediction model for pT2+ and NOC-UTUC, based on readily available imaging and ureteroscopic grade. Further research is needed to determine whether use of this prediction model to select patients for conservative management vs RNU, neoadjuvant chemotherapy, and/or extended lymphadenectomy will improve patient outcomes.
BJU International 06/2011; 109(1):77-82. · 2.84 Impact Factor
ABSTRACT: We describe the presentation, endovascular management and functional outcomes of 15 patients with renal arterial pseudoaneurysm following open and laparoscopic partial nephrectomy.
An institutional review board approved, Health Insurance Portability and Accountability Act compliant retrospective review of a prospectively maintained database revealed that 7 of 1,160 patients who underwent open partial nephrectomy and 8 of 301 treated with laparoscopic partial nephrectomy were diagnosed with a pseudoaneurysm of a renal artery branch between 2003 and 2010. Some cases were associated with arteriovenous fistula.
Diagnosis of pseudoaneurysm was made a median of 14 days after surgery. Gross hematuria was the most frequent symptom. Median estimated glomerular filtration rate measurements at the preoperative evaluation, postoperatively, on the day the vascular lesion was diagnosed, after embolization and at the last followup were 62, 55, 55, 56 and 58 ml/minute/1.73 m(2), respectively. Median followup was 7.8 months. All patients underwent angiography and superselective coil embolization of 1 or more pseudoaneurysms with or without arteriovenous fistula. Eleven patients had immediate cessation of symptoms while 4 had persistent gross hematuria after the procedure. Of these 4 patients 2 were treated with bedside care, 1 required repeat embolization with thrombin, which was successful, and the remaining patient had coagulopathy and underwent radical nephrectomy for persistent bleeding.
Pseudoaneurysms and arteriovenous fistulas of the renal artery are rare complications of partial nephrectomy. Presentation is often delayed. Superselective coil embolization is a safe, minimally invasive treatment option that usually solves the clinical problem and preserves renal function.
The Journal of urology 06/2011; 185(6):2061-5. · 4.02 Impact Factor
ABSTRACT: The impact of unfavorable pelvic anatomy on the likelihood of having a nerve sparing radical retropubic prostatectomy (RRP) and the potential correlation between pelvic dimensions and recovery of erectile function (EF) after RRP have not been previously evaluated.
To determine the impact of different pelvic bony and soft tissue dimensions as well as apical prostate depth on the likelihood of performing bilateral nerve sparing and on recovery of EF after RP.
Between November 2001 and June 2007, 644 potent men undergoing RRP had preoperative MRI where pelvimetry was performed with bilateral nerve sparing in 504 men. Outcomes including varying degrees of recovery of EF (level 1: normal; level 2: partial erections routinely sufficient for intercourse; level 3: partial erections occasionally sufficient for intercourse) were assessed. Median follow-up was 44.1 (interquartile range: 29.2, 65.3) months. We evaluated independent predictors of performing a bilateral nerve sparing procedure and of recovery of EF using multivariable Cox proportional hazards methods.
Likelihood of performing bilateral nerve sparing as well as recovery of EF after RRP.
Patients with higher clinical stage and biopsy Gleason score are less likely to undergo bilateral nerve sparing. Surgeon is also a factor in the likelihood of having bilateral nerve sparing RRP. On multivariate Cox regression analysis, factors predictive of recovery of EF were age, pretreatment erectile function, surgeon, and modified Charlson score. None of the pelvimetric dimensions were significant predictors of any degree of recovery of EF. However, the study is limited by its retrospective nature and by being based on MRI evaluations useful for cancer staging rather than anatomical evaluation of pelvimetric dimensions.
We did not find unfavorable pelvic anatomy to impact the likelihood of performing a nerve sparing procedure or to be predictive of any degree of recovery of EF after RRP.
Journal of Sexual Medicine 02/2011; 8(2):567-74. · 3.55 Impact Factor
ABSTRACT: • To analyse the clinical characteristics and outcomes of patients who underwent nephrectomy for solitary, isolated metastatic disease to the kidney.
• From July 1989 to July 2009, we identified 13 patients who underwent nephrectomy for solitary metastasis to the kidney. Patients' demographics, intra-operative variables and outcomes are reported.
• The median age at nephrectomy was 52 years (range 33-79). Eleven patients (85%) had an incidentally discovered renal mass, whereas two patients (15%) presented with gross haematuria. • Median time from initial surgery at the primary site to development of metastatic disease to the kidney was 63 months (range 9-136). No patient had evidence of disease at other sites at the time of nephrectomy. In seven patients (54%), the kidney was the first site of recurrence. • The most common primary site was the lung in five patients (38%), followed by the colon in two (15%), chest wall in two (15%) and bone, brain, breast and salivary gland in one patient each (8%). • Of the 14 procedures performed, eight (57%) were partial nephrectomy (PN) and six (43%) were radical nephrectomy (RN). • Four patients died after progression from the primary tumour, all within 2 years of nephrectomy. One patient with a primary chondrosarcoma had no evidence of disease at last follow-up and died from other causes 50 months after nephrectomy. The median follow-up for the eight patients who were alive at last follow-up was 30 months after nephrectomy. Four of these patients had no evidence of disease and four patients were alive with metastatic disease.
• Kidney involvement by metastatic disease can occur as isolated solitary lesions. Some patients will also have the kidney as the first and only site of metastatic involvement. The presence of an isolated renal metastasis should not be considered an end-stage disease, and nephrectomy can be offered for highly selected patients as a therapeutic option.
BJU International 11/2010; 108(3):338-42. · 2.84 Impact Factor
ABSTRACT: Open radical nephroureterectomy (ORN) is the current standard of care for upper tract urothelial carcinoma (UTUC), but laparoscopic radical nephroureterectomy (LRN) is emerging as a minimally invasive alternative. Questions remain regarding the oncologic safety of LRN and its relative equivalence to ORN.
Our aim was to compare recurrence-free and disease-specific survival between ORN and LRN.
We retrospectively analyzed data from 324 consecutive patients treated with radical nephroureterectomy (RN) between 1995 and 2008 at a major cancer center. Patients with previous invasive bladder cancer or contralateral UTUC were excluded. Descriptive data are provided for 112 patients who underwent ORN from 1995 to 2001 (pre-LRN era). Comparative analyses were restricted to patients who underwent ORN (n=109) or LRN (n=53) from 2002 to 2008. Median follow-up for patients without disease recurrence was 23 mo.
All patients underwent RN.
Recurrence was categorized as bladder-only recurrence or any recurrence (bladder, contralateral kidney, operative site, regional lymph nodes, or distant metastasis). Recurrence-free probabilities were estimated using Kaplan-Meier methods. A multivariable Cox model was used to evaluate the association between surgical approach and disease recurrence. The probability of disease-specific death was estimated using the cumulative incidence function.
Clinical and pathologic characteristics were similar for all patients. The recurrence-free probabilities were similar between ORN and LRN (2-yr estimates: 38% and 42%, respectively; p=0.9 by log-rank test). On multivariable analysis, the surgical approach was not significantly associated with disease recurrence (hazard ratio [HR]: 0.88 for LRN vs ORN; 95% confidence interval [CI], 0.57-1.38; p=0.6). There was no significant difference in bladder-only recurrence (HR: 0.78 for LRN vs ORN; 95% CI, 0.46-1.34; p=0.4) or disease-specific mortality (p=0.9). This study is limited by its retrospective nature.
Based on the results of this retrospective study, no evidence indicates that oncologic control is compromised for patients treated with LRN in comparison with ORN.
European urology 11/2010; 58(5):645-51. · 7.67 Impact Factor
ABSTRACT: Although oncologic outcomes appear to be similar after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN), data on renal function are lacking.
To evaluate the change over time in renal function after LPN and OPN.
We identified 987 patients with a single sporadic tumor and a normal contralateral kidney who were treated by LPN (n=182) and OPN (n=805) between January 2002 and July 2009.
All patients underwent LPN or OPN at Memorial Sloan-Kettering Cancer Center.
Estimated glomerular filtration rate (GFR) was calculated using the abbreviated Modification of Diet in Renal Disease formula. We created a multivariable generalized estimating equations linear model that predicted GFR based on the time from surgery, preoperative GFR, tumor size, American Society of Anesthesiologists score, and ischemia time.
Mean patient age, tumor size, and ASA score were similar between LPN and OPN patients. The baseline preoperative GFR was lower in the laparoscopic group (67 ml/min per 1.73 m(2) vs 73 ml/min per 1.73 m(2); p<0.001). The mean ischemia time was shorter after LPN than OPN (35 min vs 40 min, respectively; p<0.001). In a multivariable model, the interaction term between time from surgery and approach was statistically significant (p=0.045), indicating that there was a differential effect on recovery of renal function over time by approach. Laparoscopically treated patients maintained a slightly higher renal function than those treated via an open approach. The 2-mo and 6-mo predicted GFR for a typical patient increased slightly from 65 ml/min per 1.73 m(2) to 67 ml/min per 1.73 m(2), respectively, for those treated laparoscopically but remained constant at 62 ml/min per 1.73 m(2) after OPN.
Our data suggest that the surgical approach has a small effect on the recovery of renal function after partial nephrectomy. Laparoscopically treated patients maintained slightly higher renal function.
European urology 10/2010; 58(4):596-601. · 7.67 Impact Factor
ABSTRACT: The prognostic impact of primary tumor location on outcomes for patients with upper-tract urothelial carcinoma (UTUC) is still contentious.
To test the association between tumor location and disease recurrence and cancer-specific survival (CSS) in patients treated with radical nephroureterectomy (RNU) for UTUC.
Prospectively collected data were retrospectively reviewed from 324 consecutive patients treated with RNU between 1995 and 2008 at a single tertiary referral center. Patients who had previous radical cystectomy, preoperative chemotherapy, previous contralateral UTUC, or metastatic disease at presentation were excluded. This left 253 patients for analysis. Tumor location was categorized as renal pelvis or ureter based on the location of the dominant tumor. Recurrences in the bladder only, in nonbladder sites, and in any site were analyzed.
All patients were treated with RNU.
Recurrence-free survival and CSS probabilities were estimated using Kaplan-Meier and Cox regression analyses.
Median follow-up for survivors was 48 mo. The 5-yr recurrence-free probability (including bladder recurrence) and CSS estimates were 32% and 78%, respectively. On multivariable analysis, pathologic stage was the only predictor for disease recurrence (p=0.01). Tumor location was not an independent predictor for recurrence (hazard ratio: 1.19; p=0.3), and there was no difference in the probability of disease recurrence between ureteral and renal pelvic tumors (p=0.18). On survival analysis, we also found no differences between ureteral and renal pelvic tumors on probability of CSS (p=0.2). On multivariate analysis, pathologic stage (p<0.0001) and nodal status (p=0.01) were associated with worse CSS. This study is limited by its retrospective nature.
Our study did not show any differences in recurrence and CSS rates between patients with ureteral and renal pelvic tumors treated with RNU.
European urology 10/2010; 58(4):574-80. · 7.67 Impact Factor
ABSTRACT: Women have been associated with adverse outcomes after radical cystectomy for lower tract urothelial carcinoma. We evaluated the prognostic value of gender in an international cohort of patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).
We retrospectively studied 754 patients treated with RNU for UTUC without neoadjuvant chemotherapy at nine centers located in Asia, Canada, and Europe. Univariable and multivariable Cox regression analyses were used to address recurrence-free (RFS) and cancer-specific survival (CSS) estimates. Median follow-up was 40 months (interquartile range: 18-75).
The majority of patients was of men (516, 68.4%). Women were older than men at the time of RNU (median: 69.2 vs. 66.5 years; P = 0.0003). Women were less likely to have high-grade disease, undergo lymph node dissection, and to receive adjuvant chemotherapy. Gender was not associated with pathologic stage, lymph node metastasis, lymphovascular invasion, concomitant CIS, tumor architecture, or tumor necrosis. On univariable Cox regression analyses, there was no association between gender and cancer recurrence (P = 0.76) or cancer-specific mortality (P = 0.30). On multivariable Cox regression analyses that adjusted for the effects of clinicopathologic features, gender was not associated with disease recurrence (P = 0.47) or cancer-specific survival (P = 0.15).
We found no difference in histopathologic features and outcomes between men and women treated with RNU for UTUC. Nevertheless, epidemiologic and mechanistic molecular studies should be encouraged to design, analyze, and report gender-specific associations to aid in our understanding of gender impact on UTUC incidence, progression, and metastasis.
World Journal of Urology 10/2010; 29(4):481-6. · 2.41 Impact Factor
European urology 09/2010; · 7.67 Impact Factor