In 2019, our center attempted to transition all partial nephrectomies (PNs) to robotic-assisted laparoscopic PN (RALPN). The purpose of this study was to compare RALPN outcomes to laparoscopic PN ...(LPN) and open PN (OPN) at our institution, as there is limited literature from Canadian centers.
In this single-center, two-surgeon, retrospective cohort study, we compared RALPN outcomes during the early phase of our robotics program to OPN and LPN performed just before the introduction of RALPN.
A total of 106 patients underwent OPN, 83 LPN, and 82 RALPN during the study period. Median RALPN RENAL score was 7 vs. 6 for LPN (p<0.05) and 8 for OPN (p=0.10). Median RALPN length of stay (LOS) was two days vs. three and four days for LPN and OPN (p<0.05), respectively. OPN median procedure time was 104 minutes vs. 94 and 82 minutes for LPN and RALPN (p<0.05), respectively. Median OPN operating room (OR) time was 160 minutes vs. 150 and 146 minutes for LPN and RALPN (p<0.05), respectively. There were no significant differences in intraoperative (p=0.92) or postoperative complications rates (p=0.47). RALPN warm ischemia time (WIT) was 17 minutes vs 14.5 and 15 minutes for OPN and LPN (p<0.05), respectively. Median RALPN estimated blood loss (EBL) was 165 ml vs. 250 ml for OPN (p<0.05) and 125 ml for LPN (p=0.15).
Although patients who underwent RALPN had longer WIT, they had similar rates of complications, required less total OR time, and had shorter procedure time and LOS compared with OPN and LPN despite similar RENAL score compared to OPN and greater score than LPN.
Abstract Background Most early stage kidney cancers are renal cell carcinomas (RCCs), and most are diagnosed incidentally by imaging as small renal masses (SRMs). Indirect evidence suggests that most ...small RCCs grow slowly and rarely metastasize. Objective To determine the progression and growth rates for newly diagnosed SRMs stratified by needle core biopsy pathology. Design, setting, and participants A multicenter prospective phase 2 clinical trial of active surveillance of 209 SRMs in 178 elderly and/or infirm patients was conducted from 2004 until 2009 with treatment delayed until progression. Intervention Patients underwent serial imaging and needle core biopsies. Measurements We measured rates of change in tumor diameter (growth measured by imaging) and progression to ≥4 cm, doubling of tumor volume, or metastasis with histology on biopsy. Results and limitations Local progression occurred in 25 patients (12%), plus 2 progressed with metastases (1.1%). Of the 178 subjects with 209 SRMs, 127 with 151 SRMs had > 12 mo of follow-up with two or more images, with a mean follow-up of 28 mo. Their tumor diameters increased by an average of 0.13 cm/yr. Needle core biopsy in 101 SRMs demonstrated that the presence of RCC did not significantly change growth rate. Limitations included no central review of imaging and pathology and a short follow-up. Conclusions This is the first SRM active surveillance study to correlate growth with histology prospectively. In the first 2 yr, the rate of local progression to higher stage is low, and metastases are rare. SRMs appear to grow very slowly, even if biopsy proven to be RCC. Many patients with SRMs can therefore be initially managed conservatively with serial imaging, avoiding the morbidity of surgical or ablative treatment.
We report the natural history of small renal masses in patients undergoing active surveillance with extended followup.
We performed a prospective cohort study in patients undergoing active ...surveillance of small renal masses diagnosed between 2001 and 2011 at a single institution. All patients underwent active surveillance of small renal masses presumed to be renal cell carcinoma based on diagnostic imaging. Reported patient outcomes included progression to treatment, metastatic disease and/or death. Linear and volumetric tumor growth rates were evaluated.
Included in study were 103 patients with a total of 107 small renal masses. Median followup was 55.5 months in patients who continued on active surveillance. Median maximum diameter and volume at diagnosis were 2.1 cm (IQR 1.5-2.7) and 4.8 cm
(IQR 1.7-11.9), respectively. At last followup 53 patients (51.5%) were alive without metastatic disease, 48 (45.6%) had died of another cause and metastatic disease had developed in 2 (1.9%), including 1 (1.0%) who ultimately died of metastatic renal cell carcinoma. The mean ± SM linear and volumetric growth rates of all small renal masses were 0.21 ± 0.03 cm per year and 6.15 ± 2.15 cm
, respectively. Study limitations include nonstandardized followup and a lack of biopsy data on most patients.
During extended followup the majority of small renal masses in patients on active surveillance display indolent behavior. The risk of progression to metastatic disease remains low.
Most reports of active surveillance (AS) of small renal masses (SRMs) lack biopsy confirmation, and therefore include benign tumors and different subtypes of renal cell carcinoma (RCC).
We compared ...the growth rates and progression of different histologic subtypes of RCC SRMs (SRMRCC) in the largest cohort of patients with biopsy-characterized SRMs on AS.
Data from patients in a multicenter Canadian trial and a Princess Margaret cohort were combined to include 136 biopsy-proven SRMRCC lesions managed by AS, with treatment deferred until progression or patient/surgeon decision.
Growth curves were estimated from serial tumor size measures. Tumor progression was defined by sustained size ≥4 cm or volume doubling within 1 yr.
Median follow-up for patients who remained on AS was 5.8 yr (interquartile range 3.4–7.5 yr). Clear cell RCC SRMs (SRMccRCC) grew faster than papillary type 1 SRMs (0.25 and 0.02 cm/yr on average, respectively, p = 0.0003). Overall, 60 SRMRCC lesions progressed: 49 (82%) by rapid growth (volume doubling), seven (12%) increasing to ≥4 cm, and four (6.7%) by both criteria. Six patients developed metastases, and all were of clear cell RCC histology. Limitations include the use of different imaging modalities and a lack of central imaging review.
Tumor growth varies between histologic subtypes of SRMRCC and among SRMccRCC, which likely reflects individual host and tumor biology. Without validated biomarkers that predict this variation, initial follow-up of histologically characterized SRMs can inform personalized treatment for patients on AS.
Many small kidney cancers are suitable for surveillance and can be monitored over time for change. We demonstrate that different types of kidney cancers grow at different rates and are at different risks of progression. These results may guide better personalized treatment.
Tumor growth varies within and between histological subtypes of small renal masses (renal cell carcinomas), which likely reflects individual host and tumor biology. Histology-specific growth rates and initial monitoring of small renal masses can inform personalized treatment for patients on active surveillance.
Abstract Background Active surveillance (AS) represents a treatment option for renal masses in patients who are not surgical candidates either because of existing comorbidities or patient choice. ...Among renal masses undergoing AS, some grow rapidly and require treatment or progress to metastatic disease. Patient and tumour characteristics related to this more aggressive behaviour have been poorly studied. Objective To report the analysis of a multi-institutional cohort of patients undergoing AS for small renal masses. Design, setting, and participants This prospective study included 82 patients with 84 renal masses who underwent AS in three Canadian institutions between July 2001 and June 2009. Intervention All patients underwent AS for renal masses presumed to be renal cell carcinoma (RCC) as based on diagnostic imaging. Measurements Age, sex, symptoms at presentation, maximum diameter at diagnosis (cm), tumour location (central/peripheral), degree of endophytic component (1–100%), and tumour consistency (solid/cystic) were used to develop a predictive model of the tumour growth rate using binary recursive partitioning analysis with a repeated measures outcome. Results and limitations With a median follow-up of 36 mo (range: 6–96), the mean annual renal mass growth rate for the entire cohort was 0.25 cm/yr (standard deviation SD: 0.49 cm/yr). Only one patient (1.2%) developed metastatic RCC. Amongst all variables, maximum diameter at diagnosis was the only predictor of tumour growth rate, and two distinct growth rates were identified. Masses that are ≥2.45 cm in largest diameter at diagnosis grow faster than smaller masses. This series was limited by its moderate sample size, although it is the largest published prospective series to date. Conclusions We confirm that most renal masses grow slowly and carry a low metastatic potential. Tumour size is a predictor of tumour growth rate, with renal masses <2.45 cm growing more slowly than masses >2.45 cm.
Patients undergoing radical nephrectomy (RN) are often admitted with protocolized bloodwork for several days following their operation, yet the clinical value of serial hemoglobin (Hgb) measurements ...has not been established. This can lead to unnecessary costs and can prolong patient stay, despite the absence of an intervention based on these lab values. This study sought to examine perioperative Hgb values and identify those patients at high risk of bleeding requiring intervention, as well as those patients who are unlikely to require further monitoring.
Patient and perioperative factors were retrospectively examined for a cohort of 259 radical nephrectomy patients from 2015-2021 in Atlantic Canada. Postoperative Hgb values and transfusion rates were recorded. A multivariate logistic regression analysis was performed to identify variables associated with requiring a blood transfusion.
Overall, 31 (12%) patients required a blood transfusion in the postoperative period. Median estimated blood loss (EBL) was 150 ml (interquartile range IQR 100-300), with a median Hgb change of 15 g/L (IQR 9-22 g/L) from preoperative to postoperative day 1 (POD1). In patients with a Hgb loss of ≤15 g/L (n=131), transfusion was only required in four of these patients (3.1%). Among those with a POD1 Hgb >100 g/L (n=199), only four (2%) required transfusion. These patients were identified to be having complications based on hemodynamic instability. Factors found to be associated on multivariate regression analysis with higher transfusion risk were age and intraoperative EBL, while higher preoperative Hgb was found to be associated with a lower transfusion risk.
In patients who have a reassuring POD1 Hgb value, with a drop of <15 g/L or an absolute value of >100 g/L, consideration can be made towards discontinuing routine Hgb testing in the absence of a clinical indication. Age, blood loss, and preoperative Hgb are factors that may affect a patient's overall risk of transfusion.
PURPOSE OF REVIEWMetastatic renal cell carcinoma (mRCC) has traditionally been treated with a combination of targeted systemic therapy and cytoreductive nephrectomy. This approach has recently become ...a topic of debate, because of new randomized data suggesting a lack of survival benefit for cytoreductive nephrectomy. We review the literature relevant to cytoreductive nephrectomy in the modern era of targeted and immune systemic therapy, and discuss the ongoing role of surgery for treatment of patients with mRCC.
RECENT FINDINGSRandomized trials in the cytokine era of systemic therapy for mRCC demonstrated a survival benefit to cytoreductive nephrectomy, which led to its widespread adoption. There is overwhelming support in favor of cytoreductive nephrectomy from large studies using retrospective data in the targeted therapy era. A recent randomized control trial (CARMENA) failed to show superiority of cytoreductive nephrectomy in combination with sunitinib, versus sunitinib alone with respect to overall survival. The trial had major limitations including selection of many poor-risk patients, which we know do not benefit from surgery. The results of CARMENA should lead to the abandonment of cytoreductive nephrectomy in poor-risk and many intermediate-risk patients with mRCC. However, there is a knowledge gap with respect to the role of cytoreductive nephrectomy in patients with good risk disease, and we argue that these patients should be strongly considered for cytoreductive nephrectomy.
SUMMARYCytoreductive nephrectomy continues to play an important role in the multidisciplinary management of mRCC; however, diligent patient selection is crucial, as only patients with good risk features are likely to derive benefit from surgery.
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