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Renal function after partial nephrectomy following intra-arterial embolization of renal tumors

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Abstract

Laparoscopic Partial Nephrectomy (LPN) after intra-arterial Embolization of renal tumors (LPNE) in a hybrid operating room allows renal tumor enucleation without dissection and clamping of the renal pedicle. The purpose was to assess the potential negative impact of embolization on the renal function. This prospective monocentric study included all patients treated with LPNE between May 2015 and June 2019. Clinical data was collected and incorporated into the UroCCR database (NCT03293563). Glomerular Filtration Rate (GFR) and Computed Tomography Renal Volume (CTRV) were compared before and after 6 months following LPNE. The mean post-operative GFR was 86.6 mL/min (SD 22.9). The mean GFR loss was 9.4% (SD 15.1) and the median renal parenchyma loss was 21 mL (SD 20.6). Using a threshold of 25% GFR loss, age was the only significant predictive factor of renal function impairment according to bivariate (59.5 vs 69.3 years, p = 0.017) and multivariable analysis (OR 1.075, CI 1–1.2], p = 0.05). Significant renal function impairment was not correlated with the renal parenchymal volume loss (OR 0.987, CI [0.95–1.02], p = 0.435). Renal function impairment after LPNE seems to be comparable to other techniques of partial nephrectomy.

Scientic Reports | (2020) 10:21352 | 
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Renal function
after partial nephrectomy
following intra‑arterial
embolization of renal tumors
Germain Bréhier 1*, Antoine Bouvier1, Louis Besnier1, Serge Willoteaux1,
Cosmina Nedelcu1, Thibaut Culty3, Christophe Aubé1,2 & Pierre Bigot3
Laparoscopic Partial Nephrectomy (LPN) after intra‑arterial Embolization of renal tumors (LPNE)
in a hybrid operating room allows renal tumor enucleation without dissection and clamping of the
renal pedicle. The purpose was to assess the potential negative impact of embolization on the renal
function. This prospective monocentric study included all patients treated with LPNE between
May 2015 and June 2019. Clinical data was collected and incorporated into the UroCCR database
(NCT03293563). Glomerular Filtration Rate (GFR) and Computed Tomography Renal Volume (CTRV)
were compared before and after 6 months following LPNE. The mean post‑operative GFR was
86.6 mL/min (SD 22.9). The mean GFR loss was 9.4% (SD 15.1) and the median renal parenchyma loss
was 21 mL (SD 20.6). Using a threshold of 25% GFR loss, age was the only signicant predictive factor
of renal function impairment according to bivariate (59.5 vs 69.3 years, p = 0.017) and multivariable
analysis (OR 1.075, CI 1–1.2], p = 0.05). Signicant renal function impairment was not correlated with
the renal parenchymal volume loss (OR 0.987, CI [0.95–1.02], p = 0.435). Renal function impairment
after LPNE seems to be comparable to other techniques of partial nephrectomy.
As a result of the increasing use of cross-sectional imaging, 40–50% of new renal cell carcinomas are now
detected at T1 stage (localized and size < 7cm) enabling a signicant reduction in mortality rates in developed
countries despite a worldwide increasing incidence1. Partial nephrectomy is now the standard surgical treat-
ment for these tumors, especially when smaller than 4cm (stage T1a)2. Improved knowledge and techniques
now allow nephron-sparing surgery, reducing the risk of cardiovascular events and morbi-mortality related to
impaired renal function3,4.
Feasibility and positive clinical outcomes of a new technique, Laparoscopic Partial Nephrectomy (LPN) aer
intra-arterial Embolization of renal tumors (LPNE) in a hybrid operating room, have been established in recent
studies5,6. Most importantly, pre-operative embolization avoids per-procedural hilar clamping commonly used
in partial nephrectomy procedures for bleeding control, since hilar clamping time is presumed to be a modi-
able surgical risk factor for decreased renal function aer partial nephrectomy7,8. While the eect of the dura-
tion of ischemia on renal function is still a matter of debate, post-operative renal function is clearly correlated
with the quality and quantity of the residual renal parenchyma 7,9. LPNE allows surgery with zero ischemia but
requires intra-arterial injection of an iodinated contrast medium and the sacrice of a small portion of healthy
parenchyma.
e purpose of this study was to assess a potential signicant renal function impairment following LPNE and
to identify potential predictive factors for signicant impaired renal function.
Materials and methods
Population. e clinical data reports for the study were collected and incorporated into the UroCCR data-
base (French Research Network for Kidney Cancer, ClinicalTrials.gov Identier NCT03293563), which is IRB-
approved (Comité Consultatif sur le Traitement de l’Information en Matière de Recherche dans le domaine de la
Santé) and obtained the CNIL (Commission Nationale de l’Informatique et des Libertés) authorization number
DR-2013-206. All methods were carried out in accordance with relevant guidelines and regulations. is pro-
OPEN
            
      
 *
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spective monocentric study included all patients treated for a renal tumor between May 2015 and June 2019 by
LPNE.
e inclusion criterion was one single localized kidney tumor. e indication for partial nephrectomy was
validated by a multidisciplinary uro-oncologic board.
Patients who underwent Magnetic Resonance Imaging (MRI) instead of Computed Tomography (CT) scans
before surgery, patients who did undergo CT scans but not performed in our institution and patients with a
single kidney were excluded.
Procedure. All combined procedures were performed under general anaesthesia in a hybrid operating room
(Discovery IGS 730, GE Healthcare, Waukesha, WI). Concerning the unfolding of the procedure, rst of all,
an interventional radiologist performed a super-selective intra-arterial embolization of the renal tumor, then a
surgeon carried out the laparoscopic partial nephrectomy. All embolization and surgical procedures were con-
ducted as previously described (Fig.1)5.
Figure1. 44-year-old woman operated on for right kidney renal clear cell carcinoma (pT1a, complete
resection). (a) Selective arteriography shows a tumoral blush at the lower pole of right kidney (arrows). (b) Aer
embolization, the renal arteriography shows complete tumoral devascularization (arrows) with minimal defect
(arrowhead) of the peri-tumoral renal parenchyma. (c) Pre-operative CT scan shows the lower polar tumor
(arrowhead). (d) Sagittal sections of a tubular time CT scan 6months post-operatively show the operating area
with minimal cortical thinning (arrow) and hyperdense embolization material (arrowhead).
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Data and analysis. Pre-operative patient clinical data and tumor characteristics were retrieved: age, sex,
BMI, tumor size and renal tumor complexity score (R.E.N.A.L. nephrometry score; score of 4–6: low complexity;
score of 7–9: moderate complexity; score of 10–12: high complexity)10.
It is well established that the least invasive and most innocuous way to model renal function is the estimation
of the glomerular ltration rate (GFR) using standard formulas (according to Cockcro-Gault or MDRD) mainly
based on creatinine blood levels. Furthermore, excellent correlation has been shown between isotopic imag-
ing methods presumed to obtain accurate measurements of glomerular ltration rates and CT measured renal
volume (CTRV) used for pre-operative management and oncologic follow-up11. CT based volume assessment
techniques have already been used to calculate dierential kidney function, to show the dominant kidney prior
to kidney donation and even to estimate the risk of chronic kidney disease aer partial nephrectomy1214. We
therefore chose to use GFR (estimated by MDRD formula) and parenchymal renal volume (CTRV) as reective
of renal function.
Creatinine levels and MDRD clearance were collected as the pre-operative CT scans were performed and at
6months follow-up aer surgery. All CT scans were conducted according to a multiphasic protocol including an
initial non-contrast-enhanced phase followed by an arterial and/or parenchymal contrast-enhanced phase aer
intravenous injection of an iodinated contrast medium. All images were transferred to a workstation running
personal computer-based soware (SYNAPSE 3D, Fujilm Corporation, Tokyo, Japan) already used in previous
studies concerning renal volume calculation1517. Using enhanced CT phases, the aforementioned soware rst
performed an automatic extraction of the volume of both kidneys then adjusted by the operator using dier-
ent correction tools to obtain the denitive renal volume. All analysis was performed by a junior and a senior
radiologist. Ipsilateral and contralateral kidney volumes were measured excluding vessels, urinary tract, tumor
volume (in the pre-operative work-up), sequelar unenhanced areas or spontaneously hyperdense material cor-
responding to embolization devices (in the post-operative work-up).
Procedure-related data were collected: embolization procedure time, number of subsegmental arteries embo-
lized, volume of administrated iodinated contrast media, laparoscopy time, blood loss volume, requirement of
hilar clamping or embolization for secondary bleeding.
Statistical design plan. We compared data before and 6months aer LPNE. For comparison, the × 2 test
or Fisher’s test were used for qualitative variables, and Student’s t test was used for quantitative variables. Sig-
nicant GFR loss was considered when GFR was reduced by 25% aer surgery. is threshold was already used
in the elaboration of a nomogram to predict renal function loss aer partial nephrectomy for cancer18. Paired
T-test was used to compare kidney volumes before and aer surgery. Bivariate and multivariable logistic regres-
sion analysis were used to assess prognostic factors inuencing signicant GFR loss (> 25%). Only signicant
factors in the bivariate analysis were included in the multivariable analysis. e analyses were performed using
SPSS version 15.0 soware (IBM Analytics, USA). 95% Condence Interval (CI) and Odd-Ratio (OR) were used
to report results. Alpha risk was 5%.
Research involving human participants and/or animals. e clinical data reports for the study
were collected and incorporated into the UroCCR database (French Research Network for Kidney Cancer,
ClinicalTrials.gov Identier NCT03293563), which is IRB-approved (Comité Consultatif sur le Traitement de
l’Information en Matière de Recherche dans le domaine de la Santé) and obtained the CNIL (Commission Nation-
ale de l’Informatique et des Libertés) authorization number DR-2013-206.
Informed consent. Patients gave their informed consent.
Results
Patient and tumor characteristics. During this period, 137 patients were treated by LPNE. We excluded
44 patients (12 with single kidney and 28 without pre or post-operative CT-scan). Mean age was 60.4years
(SD 12.3), mean BMI was 27.4kg/m2 (SD 5). According to R.E.N.A.L. tumor complexity score, 11 (11.8%), 46
(49.5%) and 36 (38.7%) tumors were respectively of high, moderate and low complexity. Mean tumor size was
3.4cm (SD 1.6). In 4 cases (4.3%) the surgical margins were positive. e histology of the tumors is detailed in
Table1.
Peri‑operative data. Mean total operative time was 153.0min (SD 38). In 54 cases (58.1%) two or more
subsegmental arteries (up to 4) were embolized. Mean volume of administrated iodinated contrast media was
68.5mL (SD 68.5). Mean blood loss was 258.0mL (SD 459), no hilar clamping was necessary. No secondary
bleeding or embolization was reported. Perioperative data are reported on Table1.
Kidney function evolution. Pre-operative mean GFR-MDRD was 95.7mL/min (SD 23.7), mean GFR-
MDRD at 6months was 86.6mL/min (SD 22.9). Mean GFR-MDRD loss at 6months aer combined procedure
was 9.4% (CI [6.7–12.5], p value < 0.001). Signicant decrease of GFR-MDRD occurred in 10 patients (10.6%), 1
patient with no pre-operative kidney disease presented a new-onset chronic kidney disease. None of the patients
required dialysis.
Mean pre-operative global, ipsilateral and contralateral renal volume were respectively 332.0mL (SD 74.5),
164.0mL (SD 40) and 168.0mL (SD 39.2). Mean global, ipsilateral and contralateral renal volume at 6months
were respectively 315.6mL (SD 72.4), 143.0mL (SD 38.4) and 172.7mL (SD 41.6). Global renal volume, ipsilat-
eral and contralateral renal volume dierence of means were signicant, respectively −16.5mL (CI [10.2–22.7],
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p value < 0.001), −21.0mL (CI 16.8–25.3], p value < 0.001), + 4.7mL (CI [− 7.9; −1.5], p value = 0.004). Renal
function and volume evolution are reported on Table2.
Age was the only parameter significantly associated with > 25% loss of renal function (OR 1.075, CI
[1.0–1.155], p value = 0.05). e mean operative time (OR 1.01, CI [0.99–1.03], p value = 0.32) and the mean
parenchymal loss of operated kidney (OR 0.987, CI [0.95–1.02], p value = 0.435) were not correlated with signi-
cant loss of renal function. Bivariate and multivariable analysis of predictive factors of signicant renal function
decrease are respectively reported on Tables3 and 4.
Discussion
is descriptive study of functional renal outcomes aer tumor vessels embolization and partial nephrectomy
showed encouraging results. We found a moderate rate of renal function loss at 6months estimated at 9.4%, con-
sidered to be in the high range but still comparable to known results aer partial nephrectomy: a meta-analysis
conducted in 2015 reported an average overall loss of renal function of about 10% aer partial nephrectomy for
Table 1. Patient and tumor characteristics, peri-operative data.
Patient characteristics
Mean age, year (SD) 60.4 (12.3)
Male, n (%) 57 (61.3)
Mean Body Mass Index, kg/m2 (SD) 27.4 (5)
Tumor characteristics
T stage, n (%)
T1a 63 (67.7)
T1b-2 30 (32.3)
R.E.N.A.L. tumor complexity, n (%)
Low (1–6) 36 (38.7)
Intermediate (7–9) 46 (49.5)
High (10 and more) 11 (11.8)
Mean tumor size, cm (SD) 3.4 (1.6)
Benign histology, n (%) 16 (17.2)
Oncocytoma 10 (10.7)
Angiomyolipoma 4 (4.3)
Cystic 1 (1)
Metanephric adenoma 1 (1)
Malignant histology, n (%) 77 (82.8)
Clear cell renal cell carcinoma 51 (54.8)
Chromophobe renal cell carcinoma 8 (8.6)
Papillary renal cell carcinoma 17 (18.3)
Carcinoma of collecting duct 1 (1)
Positive surgical margins 4 (4.3)
Table 2. Renal function and volume evolution.
Pre-operative Follow-up 6months
GFR-MDRD
Mean GFR, mL/min (SD) 95.7 (23.7) 86.6 (22.9)
Dierence of means, mL/min (SD) [t-test] 9.6 (15.1) [p < 0.001]
Signicant renal function decrease, n (%) 10 (10.6)
Pre-operative chronic kidney disease, n (%) 4 (4.3%)
New chronic kidney disease, n (%) 1 (1)
Computed tomography renal volume
Mean global renal volume, mL (SD) 332 (74.5) 315.6 (72.4)
Dierence of means, mL/min [t-test] 16.5 [p < 0.001]
Mean treated renal volume, mL (SD) 164 (40) 143 (38.4)
Dierence of means, mL/min (SD) [t-test] 21 (20.6) [p < 0.001]
Mean contralateral renal volume, mL (SD) 168 (39.2) 172.7 (41.6)
Dierence of means, mL/min (SD) [t-test] 4.7 (15.5) [p = 0.004]
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patients with 2 kidneys19. We reported a moderate volume loss of the treated kidney at 6months (about 12.5%
i.e. 21.0mL), these results are supported by Takagi etal. study (volume loss of 18%) and Mir etal. study (volume
loss of 17%) aer partial nephrectomy20,21. We reported minimal compensatory hypertrophy of the contralat-
eral kidney of 2.9% (4.7mL), also comparable to the work of Takagi etal. (2.2%) and Mir etal. (5%), appearing
to be lower than in Jeon etal. (9.1%)2022. As marked compensatory hypertrophy is a marker of parenchymal
destruction of the operated kidney (contralateral hypertrophy of the order of 20% aer radical nephrectomy),
this minimal contralateral hypertrophy is an additional argument to conrm that embolization before partial
nephrectomy is to be considered a nephron-sparing technique.
Whether or not to perform renal arterial clamping during partial nephrectomy is still debated, one meta-anal-
ysis seemed to show a better preservation of renal function in the short and medium term with the "o-clamp"
technique, but another meta-analysis with a longer follow-up period showed that at 5years the dierence in renal
function was no longer signicant between the on-clamp and o-clamp methods23,24. However, if a clamp appears
necessary to control bleeding, its duration (< 25min) and selectivity will lead to better functional results25.
While arterial clamping remains controversial, preservation of the quantity and quality of renal parenchyma
is essential7,9. is preservation rst involves the surgical technique of tumor enucleation, which makes it pos-
sible to avoid removing healthy peritumoral parenchyma with acceptable oncological outcomes26. Second, this
preservation is also the result of performing superselective embolization, supported by state-of-the-art tools such
as CBCT, endovascular guidance soware, microcatheters and embolization devices. e absence of any nega-
tive impact of the number of embolized arteries on post-operative renal function is a good illustration of this.
Although the margin of healthy embolized parenchyma is minimal, it is nevertheless sucient to ensure
satisfying haemorrhagic control, as evidenced by the mean blood loss we reported (258.0mL), similar to that
observed (276.8mL) in a study performed with arterial clamping27. In this aforementioned study, despite the
presence of arterial clamping, 16 patients out of 289 presented secondary bleeding requiring embolization,
whereas no embolization for haemorrhage was reported in our work, conrming the results already published in
a previous study5,27. e choice of glue as embolization material, lling the lumen of the distal arterioles, allows
for immediate eective embolization and possibly more complete embolization than coils. ese elements may
explain the excellent control of bleeding shown in our work.
e multivariable analysis showed that only age is correlated with the occurrence of signicant impairment of
renal function, these results are corroborated by the results of Jeon etal. study22. Similarly, Lane etal. has shown
Table 3. Bivariate analysis of predictive factors of signicant renal function decrease.
< 25% RF loss ≥ 25% RF loss p
Mean age, year (SD) 59.5 (12) 69.3 (7.8) 0.017
Mean BMI (SD) 27.1 (5) 29.7 (4.3) 0.138
BMI > 30, n (%) 28 (34) 5 (50) 0.318
T stage, n (%) 0.72
T1a 57 (69) 6 (60)
T1b-2 26 (31) 4 (40)
R.E.N.A.L. tumor complexity, n (%) 0.136
Low (1–6) 32 (38) 4 (40)
Intermediate (7–9) 43 (52) 3 (30)
High (10 and more) 8 (10) 3 (30)
Mean tumor size, cm (SD) 3.3 (1.5) 3.7 (2) 0.56
Mean operative time, min (SD) 150.0 (37) 174.0 (39) 0.062
Mean Blood loss, mL (SD) 235.0 (451) 456.0 (497) 0.151
Number of arteries embolized, n (%) 0.86
1 35 (42) 4 (40)
2 or more 48 (58) 6 (60)
Mean iodinated contrast medium used, mL (SD) 68.4 (27) 68.8 (11) 0.97
Mean preoperative GFR, mL/min (SD) 95.7 (24) 95.4 (22) 0.96
Pre-operative Chronic kidney disease 3 (4) 1 (10) 0.371
Mean renal parenchyma loss, mL (SD) 19.0 (20) 31.0 (17) 0.077
Table 4. Multivariable analysis of predictive factors of signicant renal function decrease.
OR CI p
Mean age, year (SD) 1.075 1–1.155 0.05
Mean operative time, min (SD) 1.01 0.99–1.03 0.32
Mean renal parenchyma loss, mL (SD) 0.987 0.95–1.02 0.435
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that high age, among other non-modiable factors, is associated with decreased post-operative renal function9.
Elderly patients, regardless of the surgery performed, appear to have decreased renal function aer surgery,
probably related to a natural deterioration in renal function that would occur even if they did not undergo any
surgical procedure.
Even though this procedure requires two operators working successively, the total operating time (153.0min
[SD 38]) is similar to conventional procedures (for example 141.3min in George etal. work)27. is is possibly
explained by the injection of blue dye into the tumor vessels, that facilitates tumor spotting through the peri-renal
fat and the time saved due to the lack of renal hilum control6.
Considering the excellent control of haemorrhagic complications and observing the duration of hospitalisa-
tion, despite the cost of the material necessary for tumor vessels embolization, it would be interesting to compare
the cost-eectiveness of our combined procedure versus a robot-assisted procedure.
Our study limitations include rstly the relatively short follow-up time aer surgery. For our cohort it would
be interesting to collect GFR-MDRD results 2years aer surgery to assess if a delayed recovery of renal function
occurred as shown in Zabor etal. work which found that 2years aer surgery, 45% of patients had recovered
renal function similar to pre-operative function, with a more likely recovery in female patients, having a large
tumor size and an already impaired pre-operative renal function28. e second limitation is the small size of
the cohort, a larger sample size could have allowed other lines of statistical analysis, such as the occurrence of
new-onset chronic renal failure or a shi from moderate to severe chronic renal disease (GFR < 30mL/min).
Finally, we did not collect the presence or degree of albuminuria, which could have been of interest as a follow-
up parameter or as a prognostic factor, as pointed out in the Huang etal. study29.
Conclusion
e loss in GFR-MDRD and renal parenchyma volume (CTRV) aer LPNE seems to be comparable to results
already found in numerous published works in medical literature using other partial nephrectomy techniques.
ere was no correlation between the number of embolized arteries or renal parenchymal volume loss and renal
function loss. Age was the only parameter signicantly associated with > 25% loss of renal function. e main
interest of this surgical technique is to facilitate the tumor excision while reducing the risk of bleeding.
Data availability
The clinical data reported for the study were collected within the framework of the UroCCR project
(NCT03293563).
Received: 20 July 2020; Accepted: 19 November 2020
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Acknowledgements
We thank all the patients and the team. e anesthesia team: Dr. A. Ter-Minassian, Dr. E. Rineau; the radiology
team: D. Dabli, D. Lefort, N. Leroy, C. Vrignaud; and the surgical team: P. Panayotopoulos, V. Le Corre.
Author contributions
Protocol/project development: P.B., A.B., G.B. Data collection or management: G.B., T.C. Data analysis: G.B.,
P.B., A.B. Manuscript writing/editing: G.B., P.B., A.B., L.B., S.W., C.N., T.C., C.A.
Competing interests
Pierre Bigot and Antoine Bouvier are consultants for GE Healthcare. Other authors do not have conict of
interest related to this study.
Additional information
Correspondence and requests for materials should be addressed to G.B.
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... Selective arterial embolization (SAE) is a widely studied method for decreasing the vascularity and volume of renal malignancies, thereby facilitating subsequent complete surgical tumor excision and limiting intraoperative bleeding [20][21][22][23]. In a nested matched case-control study, survival in 118 patients who underwent renal artery embolization before nephrectomy for renal cell carcinoma was 62% and 47% at 5 and 10 years, respectively, compared with 35% and 23% in 116 patients without pre-operative embolization [22]. ...
... In a nested matched case-control study, survival in 118 patients who underwent renal artery embolization before nephrectomy for renal cell carcinoma was 62% and 47% at 5 and 10 years, respectively, compared with 35% and 23% in 116 patients without pre-operative embolization [22]. A study of SAE followed by partial nephrectomy for renal tumors suggested that renal function impairment was similar to that after other partial nephrectomy techniques [23]. ...
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Article
Background: Stage T1a renal cell carcinoma (RCC) (tumors <4 cm) is usually curable. Nephron-sparing partial nephrectomy (PN) has replaced radical nephrectomy (RN) as the standard of care for these tumors. Radical nephrectomy remains the first alternative treatment option, whereas percutaneous ablation (PA), a newer, nonsurgical treatment, is recommended less strongly because of the relative paucity of comparative PA data. Objective: To compare PA, PN, and RN outcomes. Design: Observational cohort analysis using inverse probability of treatment-weighted propensity scores. Setting: Population-based SEER (Surveillance, Epidemiology, and End Results) cancer registry data linked to Medicare claims. Patients: Persons aged 66 years or older who received treatment for T1a RCC between 2006 and 2011. Interventions: PA versus PN and RN. Measurements: RCC-specific and overall survival, 30- and 365-day postintervention complications. Results: 4310 patients were followed for a median of 52 months for overall survival and 42 months for RCC-specific survival. After PA versus PN, the 5-year RCC-specific survival rate was 95% (95% CI, 93% to 98%) versus 98% (CI, 96% to 99%); after PA versus RN, 96% (CI, 94% to 98%) versus 95% (CI, 93% to 96%). After PA versus PN, the 5-year overall survival rate was 77% (CI, 74% to 81%) versus 86% (CI, 84% to 88%); after PA versus RN, 74% (CI, 71% to 78%) versus 75% (CI, 73% to 77%). Cumulative rates of renal insufficiency 31 to 365 days after PA, PN, and RN were 11% (CI, 8% to 14%), 9% (CI, 8% to 10%), and 18% (CI, 17% to 20%), respectively. Rates of nonurologic complications within 30 days after PA, PN, and RN were 6% (CI, 4% to 9%), 29% (CI, 27% to 30%), and 30% (CI, 28% to 32%), respectively. Ten percent of patients in the PN group had intraoperative conversion to RN. Seven percent of patients in the PA group received additional PA within 1 year of treatment. Limitations: Analysis of observational data may have been affected by residual confounding by provider or from selection bias toward younger, healthier patients in the PN group. Findings from this older study population are probably less applicable to younger patients. Use of SEER-Medicare linked files prevented analysis of patients who received treatment after 2011, possibly reducing generalizability to the newest PA, PN, and RN techniques. Conclusion: For well-selected older adults with T1a RCC, PA may result in oncologic outcomes similar to those of RN, but with less long-term renal insufficiency and markedly fewer periprocedural complications. Compared with PN, PA may be associated with slightly shorter RCC-specific survival but fewer periprocedural complications. Primary funding source: Association of University Radiologists GE Radiology Research Academic Fellowship and Society of Interventional Radiology Foundation.
Article
We retrospectively analyzed the factors related to postoperative cardiovascular (CV) events in patients undergoing partial nephrectomy (PN) or radical nephrectomy (RN) for clinical T1 renal cell carcinoma (RCC). We identified 570 patients who underwent PN or RN for T1 renal cell carcinoma between January 1998 and December 2009 at our institution and related hospitals. We determined the cumulative incidence rate of CV events and overall survival (OS) using Kaplan-Meier survival curves with a log-rank test, and we evaluated the risk for an increase in CV events and OS using Cox proportional hazard regression. Of the 570 patients, 171 underwent PN and 399 underwent RN. The type of surgery was not significantly related with CV events. The only factor that significantly increased the risk of CV events in both the univariate (HR 2.67, p=0.006) and multivariate analyses (HR 2.14, p=0.044) was a postoperative estimated glomerular filtration rate (eGFR) <45 ml/min/1.73 m2. Postoperative eGFR was also a significant risk factor for OS in the univariate analysis (HR 2.38, p=0.0104), but not in the multivariate model. Postoperative renal function was a significant independent predictor of the incidence of subsequent CV events.
Article
Purpose: To confirm the findings from a previous single-institution study of 572 patients from Memorial Sloan Kettering Cancer Center, in which we found that a significant proportion (49%) of patients recovered to their preoperative estimated glomerular filtration rate (eGFR) within 2 years following radical nephrectomy for renal cell carcinoma. Materials and methods: A multi-center retrospective study was conducted among 1928 patients using data contributed by three independent centers. The outcome of interest was postoperative recovery to preoperative eGFR. Data were analyzed using cumulative incidence and competing risks regression, with death from any cause treated as a competing event. Results: This study demonstrated that 45% of patients recovered to their preoperative eGFR by 2 years following radical nephrectomy. Furthermore, this study confirmed that recovery of renal function differs according to preoperative renal function, such that patients with lower preoperative eGFR have an increased chance of recovery. This study also suggested that larger tumor size and female sex are significantly associated with increased chance of renal functional recovery. Conclusions: In this multi-center retrospective study, we confirmed that over the long-term, a large proportion of patients recover to their preoperative renal function following radical nephrectomy for kidney tumors, and that recovery is more likely among those with lower preoperative eGFR.
Article
Objective: To evaluate the clinical efficacy and safety of simple tumor enucleation (TE) for clinical T1 renal cell carcinoma. Materials and methods: A systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases was performed to identify all trials that compared TE and traditional partial nephrectomy (PN) for patients with clinical T1 renal cell carcinoma. Results: A total of 7 studies involving 3,218 patients were identified and included in this meta-analysis. Compared with the PN group, the TE group had significantly shorter estimated operation times (mean difference [MD] = -21.93; 95% CI: -31.07 to -12.78; P< 0.001), shorter warm ischemia times (MD = -1.96; 95% CI: -3.80 to -0.13; P = 0.04), less blood loss (MD = -36.63; 95% CI: -57.49 to -15.77; P = 0.0006), and lower surgical complication rates (odds ratio [OR] = 0.66; 95% CI: 0.47-0.92; P = 0.02). Furthermore, there was no significant difference between the 2 groups in hospital stay duration (MD = -0.46; 95% CI: -0.93 to 0.02; P = 0.06), changes in estimated glomerular filtration rate (MD = 3.35; 95% CI: -2.78 to 9.48; P = 0.28), positive surgical margin rates (OR = 0.34; 95% CI: 0.10-1.14; P = 0.08), and local recurrence rates (OR = 0.71; 95% CI: 0.24-2.06; P = 0.52). Conclusion: Compared to traditional PN, TE is an effective and safe treatment for T1 renal tumors, and TE appears to have acceptable early oncology outcomes. Owing to the limited number of clinical trials and the predominantly retrospective data on this subject, there is a need for properly designed studies to confirm our findings.