Objective
Identifying the predictive factors for tumor recurrence after partial nephrectomy (PN) is useful to determine patients who require careful observation after surgery. Therefore, we ...investigated recurrence after partial nephrectomy (PN) in patients with clinical T1 renal cell carcinoma (RCC) and analyzed predictive factors for recurrence-free survival (RFS).
Methods
This study included 1227 patients who underwent PN for clinical T1 RCC and retrospectively investigated patients’ characteristics and tumor factors that are associated with tumor recurrence.
Results
The median patient age was 59 years, and the median tumor size was 30 mm. Although 970 (74%) and 319 (26%) patients had clinical T1a and T1b RCCs, respectively, 20 patients (1.6%) were upstaged to pathological T3a. A positive surgical margin was found in 19 (1.5%) patients. The distribution of surgical approaches was open surgery in 428 (35%) patients and minimally invasive surgery in 799 (65%) patients. With a median follow-up of 35 months (Interquartile range 19–55 months), 39 (3.2%) patients, including ten with local recurrence, five with recurrence in the ipsilateral kidney, and 28 with other organs or lymph-nude, developed recurrence. The 3-year RFS was 99%, and the median recurrence time from PN was 19 months (interquartile range: 11–37 months). Multivariate analysis identified high grade tumor and upstaging to pT3a as significant predictors for worse RFS.
Conclusion
Patients with high grade tumors and tumors upstaged to pT3 had a high risk of worse RFS, which suggested that careful monitoring is required for such patients after PN, even if a good prognosis is achieved in patients with clinical T1 RCC.
To investigate the detection of peritumoral pseudocapsule (PC) using multi-detector row computed tomography (MDCT) for tumors resected by robot-assisted laparoscopic partial nephrectomy (RAPN) for T1 ...renal cell carcinoma (RCC). Study participants included 206 patients with clinical T1 RCC who underwent RAPN between October 2017 and February 2018. Two radiologists who were blinded to the pathological findings evaluated the computed tomography (CT) images. Radiological diagnosis of a PC was defined by a combination of observations, including a low-attenuation rim between the tumor and renal cortex in the cortico-medullary phase and a high-attenuation rim at the edge of the tumor in the nephrogenic or excretory phase. A PC was detected on CT in 156/206 tumors (76%) and identified by pathology in 182/206 (88%) tumors including 153/166 (92%) clear cell RCC, 13/14 (93%) papillary RCC, and 7/16 (44%) chromophobe RCC. In the whole cohort, CT findings showed a sensitivity of 81.3% (148/182), specificity of 66.7% (16/24), and positive predictive value of 94.9% (148/156). When the data were stratified according to pathological subtypes, MDCT was observed to have a sensitivity of 86.9% (133/153) and specificity of 61.5% (8/13) in clear cell RCC, sensitivity of 38.5% (5/13) and specificity of 100% (1/1) in papillary RCC, and sensitivity of 44.4% (4/7) and specificity of 66.7% (6/9) in chromophobe RCC. A low or high-attenuation rim around the tumor in the cortico-medullary or nephrographic-to-excretory phase indicates a PC of RCC, though the accuracy is not satisfactory even with 64- or 320-detector MDCT.
Purpose
We investigated operative time according to procedure phases in robot‐assisted laparoscopic partial nephrectomy (RAPN) and identify variables associated with longer operative time in each ...procedure phase.
Methods
This retrospective, single‐center study included 108 patients who underwent RAPN conducted by an experienced surgeon. Operative time was divided into dissection, resection, tumor bed suture, and renorrhaphy and hemostasis phases, which were derived from the iPhone application “My Intuitives.” Multivariate analyses were performed to identify possible predictors such as sex, body mass index, tumor complexity, and surgical approach for longer operative time in each phase.
Results
The median console time was 65 min, and median operative times in dissection, resection, tumor bed suture, and renorrhaphy and hemostasis phases were 41, 8, 9, and 8 min, respectively. In the multivariate analysis, longer console time was observed in high complexity tumors (vs. low, OR: 8.01, 95% CI: 1.94–33.0) and transperitoneal approach (vs. retroperitoneal approach, OR: 3.62, 95% CI: 1.94–33.0). High complexity tumors were significantly associated with longer operative time in all procedure phases, and the male sex was associated with a longer operative time in the dissection phase than the female sex (OR: 3.61, 95% CI: 1.18–11.0).
Conclusion
The identified significant predictive factors associated with longer operative time were the male sex and high complexity in the dissection phase, high complexity in the resection phase, in the tumor bed suture phase as well as in the renorrhaphy and hemostasis phase. These findings may help to predict the difficulty of performing RAPN in terms of operative time.
New pathological subtypes of renal cell carcinoma (RCC) were designated in the 2016 World Health Organization (WHO) classification corresponding to the features commonly seen in patients with ...end‐stage renal disease (ESRD). To determine the clinicopathological findings of new subtypes, we reanalyzed all sections from 315 kidneys in 291 ESRD patients bearing RCC tumors surgically resected in three Japanese institutes by the central pathologist. Clear cell RCC was diagnosed in 144 kidneys (45.7%), acquired cystic disease (ACD)‐associated RCC in 100 (31.7%), papillary RCC in 41 (13.0%), and other minor subtypes in 30 (9.52%). Multivariate analysis showed that longer duration of dialysis, young age, and male sex were independent prognostic clinical factors for the occurrence of ACD‐associated RCC. ACD‐associated RCC included more WHO/International Society of Urologic Pathology (ISUP) grade 3/4 cases compared to other RCCs. In contrast, other unfavorable findings were less frequent in ACD‐associated RCC, including the presence of a sarcomatoid component, lymphovascular invasion, and necrosis. In conclusion, ACD‐associated RCC is a common histology in Japanese patients with ESRD. In addition, ACD‐associated RCC showed more cases with a higher WHO/ISUP grade, but fewer cases with other unfavorable pathological features, suggesting a favorable prognosis of ACD‐associated RCC.
Objectives
To determine the influence of the early unclamping technique on the risk of renal artery pseudoaneurysm during robot‐assisted laparoscopic partial nephrectomy.
Methods
From January 2013 to ...October 2014, 96 patients underwent robot‐assisted laparoscopic partial nephrectomy for renal masses at Tokyo Women's Medical University Hospital, Tokyo, Japan. Computed tomography angiography was carried out 3–4 days after surgery. Early in the series, renal hilum was left unclamped and renorrhaphy was subsequently carried out (conventional unclamping technique). An early unclamping technique has been used since November 2013.
Results
A total of 61 patients underwent robot‐assisted laparoscopic partial nephrectomy with early unclamping, and 35 patients underwent robot‐assisted laparoscopic partial nephrectomy with conventional unclamping. Ischemia time was significantly shorter in the early unclamping group (16.5 vs 23.1 min; P < 0.01). The early unclamping group showed a significantly lower incidence of asymptomatic renal artery pseudoaneurysm relative to the conventional unclamping group (11.4% vs 28.6%; P = 0.03). Multivariate analysis showed that the early unclamping technique was a significant independent factor in reducing the risk of renal artery pseudoaneurysm (hazard ratio 0.27; P = 0.01).
Conclusions
The present findings suggest that an early unclamping technique might reduce ischemic time and risk of renal artery pseudoaneurysm. The absence of arterial bleeding before renorrhaphy is likely to be a key step in preventing renal artery pseudoaneurysm during robot‐assisted laparoscopic partial nephrectomy.
In addition to breast, ovarian, and pancreatic cancers, BRCA1/2 genes have been associated with prostate cancer (PC). However, the role of BRCA1/2-associated family cancer history (FCH) has remained ...unexplored in treating these four cancer types as a homogenous pathophysiological group. We aimed to clarify the relationship between BRCA1/2-associated FCH and PC, and to assess its relationship with cancer aggressiveness. Patient characteristics, positive family history of BRCA1/2-associated cancer, and cancer characteristics (Gleason score, prostate specific antigen level at diagnosis, and clinical tumor stage) were analyzed. Among the 1,985 eligible candidates, 473 (23.83%) patients had adequately detailed FCH, obtained via questionnaire, and were thus included in the study. BRCA1/2-associated FCH was observed in 135 (28.54%) patients with PC (68, 14.38%), breast (44, 9.30%), pancreatic (31, 6.55%), or ovarian (8, 1.69%) cancers. BRCA1/2-associated FCH was not significantly associated with high Gleason score (≥ 8). Patients with BRCA-associated FCH were less likely to present with high clinical tumor stage, and no difference was observed in prostate-specific antigen level, presence of metastatic lesions at diagnosis, or likelihood of high-risk classification between patients with and without BRCA-associated FCH. This is the first report of BRCA1/2-associated FCH in Japanese men, indicating that family history did not affect the severity or aggressiveness of PC.
Objectives: The benefit of lymphadenectomy (LND) in patients with urothelial carcinoma of the upper urinary tract (UCUUT) has remained controversial. The aim of this study was to examine the ...influence of the LND template and the total number of lymph nodes (LN) when increasing the number of patients undergoing complete dissection of regional nodes (CompLND).
Methods: A total of 109 UCUUT patients with clinically negative nodes underwent nephroureterectomy with concomitant lymphadenectomy at our center. Patients' survival was examined according to the type of LND and the number of removed LN. Univariate analysis was performed to find the cut‐off value of LN influencing survival.
Results: Seventy‐eight patients underwent CompLND. Incomplete lymphadenectomy was performed in an additional 41 patients. In the patients with pT2 or higher who were clinically negative for nodal metastasis, any cut‐off value for the total number of LN removed showed no statistical significance. In contrast, CompLND had a significant impact on patient survival. The Cox proportional hazard model showed that CompLND was a significant factor after adjusting for adjuvant chemotherapy. The total number of removed LN was not significant.
Conclusions: In patients with muscle‐invasive clinical node‐negative UCUUT, the number of LN removed shows minimal influence on their survival. In contrast, the influence of the particular type of lymphadenectomy is statistically significant. These findings suggest that the extent of lymphadenectomy should be determined by the template and not by the number of removed LN.
Objectives
To compare surgical and functional outcomes between robot‐assisted laparoscopic partial nephrectomy and open partial nephrectomy in patients with renal cell carcinoma with stage 4 chronic ...kidney disease.
Methods
This was a retrospective analysis of 60 patients with stage 4 chronic kidney disease (estimated glomerular filtration rate 15–30 ml/min/1.73 m2) who underwent partial nephrectomy for T1 renal cell carcinoma between April 2004 and April 2020. We compared perioperative outcomes according to the surgical approach. Multivariable analysis was performed to identify predictive factors for end‐stage renal disease.
Results
Robot‐assisted laparoscopic partial nephrectomy and open partial nephrectomy were performed in 31 and 29 patients, respectively. The median age was 68 years and 17% of all patients were women. Patient and tumor characteristics did not differ between groups. The operative time (155.2 vs. 221.0 min, p < 0.0001) and the postoperative length of hospital stay (5.2 vs. 10.6 days, p = 0.0083) were significantly shorter, and the estimated blood loss was lower (53.4 vs. 363.2 ml, p = 0.0003) in the robot‐assisted laparoscopic partial nephrectomy group than in the open partial nephrectomy group. Preoperative estimated glomerular filtration rate was the only significant predictor of end‐stage renal disease after partial nephrectomy on multivariable analysis.
Conclusions
Both procedures preserved renal function in this patient cohort, delaying the requirement for postoperative dialysis. Furthermore, robot‐assisted laparoscopic partial nephrectomy was associated with shorter operative time and postoperative length of hospital stay, as well as lesser estimated blood loss than open partial nephrectomy.
Background
With new options in adjuvant settings, clinical biomarkers to predict recurrence after radical surgery for high-risk renal cell carcinoma (hrRCC) are in need but are scarcely investigated. ...We aimed to verify the predictive value of perioperative C-reactive protein (CRP) kinetics on hrRCC recurrence.
Methods
We retrospectively evaluated 154 patients who underwent radical surgery for hrRCC (≥ pT3 and/or N1-2 and M0) at two institutions. Patients were classified into Normal (< 0.5) and High (≥ 0.5) according to their preoperative serum CRP (mg/dL). The High group were further classified into Normalized (< 0.5 at post) or Non-normalized (≥ 0.5 at post), and recurrence-free survival (RFS) was compared between groups. Factors for RFS were further analysed, and Harrell’s concordance index (C-index) for the accuracy of predicting RFS was compared with and without the addition of CRP-related variables to pre-existing models.
Results
The RFS was significantly shorter in the High (
n
= 72, 46.8%) compared to the Normal (
n
= 82, 53.2%) group (9.7 vs. 66.7 months,
p
< 0.001). Within the High group, Non-normalized (
n
= 27, 17.5%) patients showed a significantly shorter RFS compared to the Normalized (
n
= 45, 29.2%) group (6.2 vs. 20.3,
p
= 0.009). In the multivariable stepwise analysis, CRP kinetics (hazard ratio 2.15,
p
= 0.029) effectively predicted RFS while baseline CRP fell short of significance. Higher C-index improvement was observed with CRP non-normalization than the baseline value when added to factors in the Karakiewicz and University of California Los Angeles Integrated Staging System models.
Conclusions
CRP kinetics effectively predicted RCC recurrence after surgery and may aid in decision-making for adjuvant systemic therapy.
We investigated the prognostic nutritional index (PNI), comprised of lymphocytes and albumin, as a potential prognosticator of metastatic urothelial carcinoma (mUC) patients receiving pembrolizumab.
...Sixty-five patients were retrospectively enrolled and classified as low (<40) and high (≥40) based on pretreatment PNI. Progression-free survival (PFS), overall survival (OS) and response rates were evaluated.
In the low PNI group, significantly shorter PFS and OS were observed. PNI was shown to be an independent predictor of PFS and OS in the multivariate analysis. C-index for both PFS and OS improved with the addition of PNI to the model described in the KEYNOTE-045 study. Significantly more patients experienced initial disease progression in the low PNI group.
PNI is a useful predictor of prognosis and disease progression in mUC patients receiving pembrolizumab.
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