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Article of the Week: Multiple Growth Periods of SRMs Predict Unfavourable Pathology

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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 discussing the paper.

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

Multiple growth periods predict unfavourable pathology in patients with small renal masses

Alex Jang , Hiten D. Patel, Mark Riffon, Michael A. Gorin , Alice Semerjian, Michael H. Johnson, Mohamad E. Allaf and Phillip M. Pierorazio

 

Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA

 

Abstract

Objective

To use the number of positive growth periods as a characterization of the growth of small renal masses in order to determine potential predictors of malignancy.

Patients and Methods

Patients who underwent axial imaging at multiple time points prior to surgical resection for a small renal mass were queried. Patients were categorized based on their pathological tumour grade and stage: favourable (benign, chromophobe and low‐grade pT1–2 renal cell carcinoma [RCC]) vs unfavourable (high‐grade of any stage and low‐grade pT3–4 RCC). A positive growth period was counted each time the difference in greatest tumour diameters between two images was positive. The Cochran–Armitage trend test and Somers’ D association were used to determine if the number of positive growth periods was correlated with unfavourable pathology.

Results

Of the 124 patients, 86 (69.4%) had favourable pathology and 38 (30.6%) had unfavourable pathology. Those who had favourable pathology were younger than those who had unfavourable pathology: median (interquartile range [IQR]) 61.0 (52.2–66.0) vs 68.5 (61.5–77.0); P < 0.001. The overall growth rate was higher in the unfavourable group, but was not statistically significant: mean (sd) 0.7 (1.7) vs 1.6 (2.8) cm/year; P = 0.07. There was a significant trend difference in the number of positive growth periods between favourability groups (P = 0.02). An association between increased number of positive growth periods and unfavourable pathology was observed: 0.15 (95% confidence interval 0.02, 0.29). The ratios of favourable to unfavourable pathology were 1.8, 1.0, 0.66, 0.59 and 0 as the number of positive growth periods increased from 0 to 4, respectively.

Conclusion

While overall growth rate was not predictive of pathology favourability, there was a positive association between the number of positive growth periods and unfavourable pathology. The number of positive growth periods may be a potential parameter for malignant potential in patients undergoing active surveillance for small renal masses.

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Editorial: Growth spurts of small renal masses correlate with pathology

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A rapid growth rate has long been known to be a harbinger of aggressive tumour pathology and clinical behaviour of small renal masses (SRMs) 1. However, this association has not been confirmed in prospective studies of patients with SRMs on active surveillance (AS) 2. Jewett et al. 2, in a multicentre prospective phase 2 clinical trial of 209 patients with a SRM, found that despite an average growth rate of 0.13 cm/year, pathology did not impact growth. Clinically, the growth rates of SRMs are most commonly variable, rather than the assumed steady slow growing rate that is often reported 3. Due to the discrepancies in the literature, the use of average growth rate for a SRM can be misleading. Finding a clinically effective tool to identify potentially aggressive cancers remains an important (and unmet) need for patients undergoing AS.

Jang et al. 4 provide insight into this need by evaluating the number of growth periods over time as a risk factor for renal masses under surveillance. They retrospectively reviewed renal masses that were initially <4 cm at diagnosis and were followed for a variable time period before undergoing surgical therapy. Two cohorts were grouped into ‘favourable‐’ (benign tumours, chromophobe RCC and low grade, pT1–2 RCC) and ‘unfavourable’‐risk tumours (high‐grade RCC of any stage and low‐grade, pT3–4 RCC), finding no difference in the amount of interval imaging between the two groups. There was a significant difference in the number of positive growth periods between the ‘favourable’ and ‘unfavourable’ pathology groups (P = 0.02) for the entire cohort (all pT stages) and a similar finding when examining only pT1a tumours (P < 0.05). Additionally, there was a positive association between increased number of positive growth periods and unfavourable pathology (odds ratio 0.15, 95% CI 0.02–0.29).

Active surveillance is considered an acceptable initial option for the management of all patients with SRMs, not just those with limited life expectancy or poor performance, as highlighted in the 2017 AUA guidelines 5. Optimal management of patients on AS would appear to require a good understanding of growth kinetics, pathological details, and risk–benefit analysis. The previously held dogma of using linear growth rate as a guide for the aggressiveness of a tumour has been challenged recently 6 and again put into question by this study 4. The Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) study showed that there was a higher growth rate in patients who had delayed intervention compared with those on AS, but there was no significant association (P = 0.15) 6. However, in the same study, the proportion of patients who had a positive growth rate (>0 cm/year) or a recorded ‘growth spurt’ were significantly more likely to have delayed intervention than AS patients (P < 0.01) 6.

Growth spurts, rather than growth rate over time, as a marker for malignancy, correlates best with clinical experience. Average growth rate can be artificially high with one large growth and multiple stable imaging intervals. One of the important elements of AS is regular interval imaging. The development of protocols that can be evaluated to determine the optimal type, interval, and duration of follow‐up imaging is a clinical need in this space. Whilst the cohort from Jang et al. 4 did not have regular intervals for imaging, there were an equal number of studies performed on patients with ‘favourable’ and ‘unfavourable’ pathology. Without clear protocols, using growth spurts rather than growth rate, also provides a simplified message for patients and will aid in counselling.

The identification of growth spurts as a risk factor for potentially aggressive features of SRMs under surveillance provides a useful tool when determining the need for intervention of a SRM. The uniform reporting of pathological data for patients under study is a strength, but several weaknesses limit the generalisability of the findings including the retrospective study design and inconsistent manner in which AS was performed. The clinical impact of growth spurts in the AS population warrants further investigation before definitive conclusions can be drawn.

Conrad M. Tobert* and Brian R. Lane†‡
*Department of Urology, University of Iowa, Iowa City, IA, USA, †Division of Urology, Spectrum Health Medi cal Group, Grand Rapids, MI, USA and ‡Michigan State University College of Human Medicine, Grand Rapids, MI, USA

 

References
  • 1 Lee SW, Sung HH, Jeon HG et al. Size and volumetric growth kinetics of renal masses in patients with renal cell carcinoma. Urology 2016; 90: 119–24

 

 

  • 3 Chawla SN, Crispen PL, Hanlon AL, Greenberg RE, Chen DY, Uzzo RG. The natural history of observed enhancing renal masses: meta‐analysis and review of the world literature. J Urol 2006; 175: 425–31

 

  • 4 Jang A, Patel HD, Riffon M et al. Multiple growth periods predict unfavourable pathology in patients with small renal masses. BJU Int 2018; 121: 732–6

 

 

 

Video: Multiple Growth Periods of SRMs Predict Unfavourable Pathology

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Multiple growth periods predict unfavourable pathology in patients with small renal masses

 

Abstract

Objective

To use the number of positive growth periods as a characterization of the growth of small renal masses in order to determine potential predictors of malignancy.

Patients and Methods

Patients who underwent axial imaging at multiple time points prior to surgical resection for a small renal mass were queried. Patients were categorized based on their pathological tumour grade and stage: favourable (benign, chromophobe and low‐grade pT1–2 renal cell carcinoma [RCC]) vs unfavourable (high‐grade of any stage and low‐grade pT3–4 RCC). A positive growth period was counted each time the difference in greatest tumour diameters between two images was positive. The Cochran–Armitage trend test and Somers’ D association were used to determine if the number of positive growth periods was correlated with unfavourable pathology.

Results

Of the 124 patients, 86 (69.4%) had favourable pathology and 38 (30.6%) had unfavourable pathology. Those who had favourable pathology were younger than those who had unfavourable pathology: median (interquartile range [IQR]) 61.0 (52.2–66.0) vs 68.5 (61.5–77.0); P < 0.001. The overall growth rate was higher in the unfavourable group, but was not statistically significant: mean (sd) 0.7 (1.7) vs 1.6 (2.8) cm/year; P = 0.07. There was a significant trend difference in the number of positive growth periods between favourability groups (P = 0.02). An association between increased number of positive growth periods and unfavourable pathology was observed: 0.15 (95% confidence interval 0.02, 0.29). The ratios of favourable to unfavourable pathology were 1.8, 1.0, 0.66, 0.59 and 0 as the number of positive growth periods increased from 0 to 4, respectively.

Conclusion

While overall growth rate was not predictive of pathology favourability, there was a positive association between the number of positive growth periods and unfavourable pathology. The number of positive growth periods may be a potential parameter for malignant potential in patients undergoing active surveillance for small renal masses.

Read more articles of the week

Article of the Week: Safety, reliability and accuracy of small renal tumour biopsies: results from a multi-institution registry

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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.

Safety, reliability and accuracy of small renal tumour biopsies: results from a multi-institution registry

Patrick O. Richard*,†, Michael A. S. Jewett*, Simon Tanguay‡, Olli Saarela§, Zhihui Amy Liu§, Frederic Pouliot, Anil Kapoor**, Ricardo Rendon†† and Antonio Finelli*

 

*Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada, †Centre Hospitalier Universitaire de Sherbrooke, Universite de Sherbrooke, Sherbrooke, QC, Canada, ‡Department of Surgery, Division of Urology, McGill University Health Center, McGill University, Montreal§Dalla Lana School of Public Health, University of Toronto, Universite Laval, Centre de Recherche du Centre Hospitalier Universitaire de Quebec, Quebec **Department of Surgery, Division of Urology, McMaster University, Hamilton and ††QEII Health Sciences Centre, Department of Urology, Dalhousie University, Halifax, NS, Canada

 

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Abstract

Objective

To validate, in a multi-institution review, the safety, accuracy and reliability of renal tumour biopsy (RTB) and its role in decreasing unnecessary treatment.

Materials and Methods

We conducted a multi-institution retrospective study of patients who underwent RTB to characterize a small renal mass (SRM) between 2011 and May 2015. Patients were identified using the prospectively maintained Canadian Kidney Cancer information system. Diagnostic and concordance rates were presented using proportions, whereas factors associated with a diagnostic RTB were identified using a logistic regression model.

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Results

Of the 373 biopsied SRMs, the initial biopsy was diagnostic in 87% of cases. Of the 47 non-diagnostic biopsies, 15 had a repeat biopsy of which, 80% were diagnostic. When both were combined, therefore, a diagnosis was obtained in 91% of SRMs. Of these, 18% were benign. Size was the only factor found to be associated with achieving a diagnostic biopsy. RTB histology and nuclear grade (high or low) were found to be highly concordant with surgical pathology (86 and 81%, respectively). Of the discordant tumours (n = 16), all were upgraded from low to high grade on surgical pathology. Adverse events were rare (<1% of cases).

Conclusion

The present multi-institution study confirms that RTB of SRMs is safe, accurate and reliable across institutions, while decreasing unnecessary treatment. Given our findings, RTBs may be a helpful tool with which to triage SRMs and guide appropriate management.

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Editorial: Renal tumour biopsy: let’s talk about it

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There has been a marked increase in the incidental diagnosis of small renal masses (SRMs), resulting in overtreatment of benign and indolent lesions. Renal tumour biopsy (RTB) has received increasing attention as a potential tool to help reduce this overtreatment, with single-institution studies reporting good safety, accuracy, and reliability. One of the purposes of paper by Richard et al. [1], appearing in this issue of BJUI, was to address whether these results of RTB were generalisable across multiple institutions. They evaluated 373 RTBs from 12 centres, reporting an initial diagnostic rate of 87%, with 32% of non-diagnostic RTBs undergoing repeat biopsy, for a combined diagnostic rate of 91%. They reported concordance rates between RTB and surgical pathology of >80% and a RTB complication rate of <1%. The generalisability of these impressive RTB results remains unclear because they were unable to report the numbers of RTB per centre (beyond ‘at least one’) and results were likely driven by a few high-volume centres.

The analysis is not without limitations. The negative predicative value (NPV) of RTB could not be assessed because there was no surgical specimen to confirm a benign RTB diagnosis. A meta-analysis by Patel et al. [2] raised concerns about a non-diagnostic or negative RTB. Of the 14% of patients with a non-diagnostic biopsy, 90% of those subsequently undergoing surgery were found to have cancer. Among patients having surgery, 37% with a negative biopsy who underwent surgical extirpation were found to have cancer on final pathology (NPV 63%). Another limitation of RTBs is that they tend to under grade tumours compared to surgical pathology. Even when using a simplified two-tiered grading system of low vs high grade tumours to improve concordance [3], 20% of patients with low-grade clear cell RCC (ccRCC) were upgraded to high-grade ccRCC at surgery. Concordance rates did not include non-diagnostic biopsies; nonetheless, their results support that a ‘good’ RTB can usually be trusted. Selection bias may have been a factor because patients who did not receive a RTB for a SRM were not included. It seems unlikely that reports of improved RTB outcomes would result in a change in guidelines to a ‘one size fits all’ policy recommending RTB in all patients with a SRM. RTB may not be feasible in some patients (anterior, hilar, cystic tumours) and may not always have potential to change clinical management, such as with a young healthy patient who is unwilling to accept any degree of uncertainty with a negative biopsy or an elderly patient with comorbidities who would not accept treatment regardless of RTB results. In this study [1], only ~25% of the patients who underwent surgery for a cT1a lesion had a RTB before surgery, possibly a reflection of the limitations of RTB, as well as some room for improvement.

Despite the limitations of RTB, the fact remains that many renal lesions are over treated, RTB outcomes are improving, and RTB may help guide clinical management. The authors [1] suggest that even a misclassified SRM could probably be managed conservatively over the short term. They recommend that even a benign RTB should be followed with serial imaging and that a repeat RTB should be considered for fast growing lesions. Perhaps the future of RCC diagnosis lies beyond the RTB and includes imaging innovations that can distinguish benign and malignant tumours and spare patients an unnecessary treatment, as well as an unnecessary biopsy. For example, Gorin et al. [4] showed that technetium-99m (99mTc)-sestamibi single-photon emission CT (SPECT)/CT could accurately distinguish renal oncocytomas and hybrid oncocytic/chromophobe tumours from other renal tumour histologies.

Current guidelines already acknowledge the potential role for RTB to guide clinical management in patients willing to accept the known limitations and who have an indeterminate SRM or are considering a range of treatment options such as active surveillance or ablation. We do not need a blanket guideline mandating upfront RTB for all. But we should at least talk about RTB with our patients with SRMs. We owe it to them to be aware of the potential benefits and limitations of RTB and include this in our discussion so they can be involved in the decision.

Read the full article
Haider Rahbar, and Craig Rogers

 

Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA

 

References

 

1 Richard PO, Jewett MA, Tanguay S et al. Safety, reliability and accuracy of small renal tumour biopsies: results from a multi- institution registry. BJU Int 2017; 119: 543–9

 

2 Patel HD, Johnson MH, Pierorazio PM et al. Diagnostic accuracy and risks of biopsy in the diagnosis of a renal mass suspicious for localized renal cell carcinoma: systematic review of the literature. J Urol 2016; 195: 1340–7

 

3 Rioux-Leclercq N, Karakiewicz PI, Trinh QD et al. Prognostic ability of simplified nuclear grading of renal cell carcinoma. Cancer 2007; 109: 868–74

 

4 Gorin MA, Rowe SP, Baras AS et al. Prospective evaluation of (99m)Tc- sestamibi SPECT/CT for the diagnosis of renal oncocytomas and hybrid oncocytic/chromophobe tumors. Eur Urol 2016; 69: 413–6

 

Article of the week: Repeat RAPN: Feasibility and early outcomes

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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.

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

Repeat robot-assisted partial nephrectomy (RAPN): feasibility and early outcomes

Riccardo Autorino, Ali Khalifeh, Humberto Laydner, Dinesh Samarasekera, Emad Rizkala, Remi Eyraud, Georges-Pascal Haber, Robert J. Stein and Jihad H. Kaouk

Center for Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

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OBJECTIVE

• To demonstrate the feasibility, and to report our single-centre perioperative outcomes of repeat robot-assisted partial nephrectomy (RAPN).

PATIENTS AND METHODS

• From June 2006 to June 2012, 490 patients underwent RAPN for a renal mass at our centre. Of these patients, nine who had undergone previous ipsilateral nephron-sparing surgery (NSS) were included in the analysis.

• Patient charts were reviewed to obtain demographic data, preoperative surgical history, operative details, and postoperative outcomes and follow-up data.

RESULTS

• In all, 12 tumours were removed in nine patients (median age 69 years; six female). A third of the operations were performed on patients with a solitary kidney. The median (range) R.E.N.A.L. nephrometry score for the resected masses was 7 (4–8).

• The warm ischaemia time was 17.5 min and in three of the nine patients an unclamped procedure was performed. No intraoperative complications were registered, whereas only two minor complications occurred postoperatively. There were no renal unit losses. All surgical margins were negative.

• There was no significant difference between mean preoperative and latest postoperative mean estimated glomerular filtration rates (70.5 vs 63.5 mL/min/1.73m2, P > 0.05).

• At a mean (sd) follow-up of 8.3 (13) months, eight of the nine patients with a pathology diagnosis of malignant neoplasm were alive and free from disease at the latest follow-up.

CONCLUSION

• Although technically more demanding, repeat RAPN can be safely and effectively performed in patients presenting with local recurrence after primary NSS for kidney cancer.

 

Read Previous Articles of the Week

 

Editorial: Robot-assisted partial nephrectomy in patients with recurrent disease: fiction or fact?

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In recent decades, the detection of small renal masses (SRMs) has steadily increased with an accompanying shift of treatment towards partial nephrectomy (PN). Indications for PN have successfully expanded to more challenging cases, and robot-assisted PN (RAPN), in particular, has attracted increasing attention (BJUI, Eur Urol); however, despite excellent cure rates for PN, parallel to the increasing number of patients with SRMs undergoing PN, cases of ipsilateral recurrence after PN are also expected to rise. In addition to the incomplete surgical removal of the primary tumour, unknown multifocality or the development of new tumours or metastasis, in a minority of cases recurrence originates at the previous surgical bed and can be considered a proper local recurrence. Retreatment in these patients represents a specific challenge with radical nephrectomy (RN), ablative treatment, repeat PN, and active surveillance in selected cases as therapeutic options. RN should be considered the least attractive option because of the further damage to renal function that it entails, yet it represents one of the most selected options worldwide. Besides ablative techniques, which should be considered under investigational circumstances only, repeat PN is one of the possible options, especially in cases of recurrences attributable to multifocality or bilateral nature.

Repeat open as well as laparoscopic PN (LPN) have been reported sparsely in the literature, but were shown to be associated with good functional and oncological outcomes given adequate laparoscopic experience and patient selection. Such procedures, however, might be challenging and fraught with complications. The role of repeat RAPN (as well as the role of repeat open PN) in this situation is yet to be defined. Nevertheless, given that current data show RAPN to be a more attractive minimally invasive PN technique compared with its standard laparoscopic counterpart, providing equal or better perioperative outcomes, its advantages may even be greater when repeat PN is indicated.

In the current issue of the journal, Autorino et al. report the first study on functional and oncological outcomes and feasibility of repeat RAPN in patients with recurrence after previous PN. Of 490 patients treated with RAPN, nine patients underwent RAPN for recurrent disease at a median time of 39.4 months after previous open or LPN. A total of 12 tumours were removed in these patients, and one third of operations were performed on solitary kidneys. No intra-operative complications were observed, and only two minor complications occurred postoperatively, which were managed conservatively. With regard to functional outcomes, there was a nonsignificant median postoperative decrease in estimated GFR of 7%. More importantly, all patients preserved adequate renal function, which meant that renal replacement therapy was not necessary. With regard to oncological outcomes, all surgical margins were negative and no recurrence was reported.

The results of another study cohort of five patients undergoing repeat RAPN for recurrent disease after open or LPN has recently been published by Jain et al. In their series, surgery was completed in all patients without conversion to RN or an open procedure; furthermore, no complications were reported and the median decrease in GFR was 10%.

Importantly, both series suffer from retrospective evaluation of selective and small sample sizes with a short follow-up, and comparative analysis with other treatment options was not performed; however, the effective comparator for RAPN in this setting has yet to been defined. Bearing in mind current data that demonstrate RAPN to be a preferable minimally invasive PN technique compared with its standard laparoscopic counterparts, the real competitor for RAPN seems to be open surgery. This point was recently also reflected by Mottrie et al. LPN, as a challenging procedure with a long learning curve, limited diffusion and prevalent application in less complex cases, cannot be considered an attractive comparator for RAPN. During the last 8 years, RAPN has become a promising technique which can overcome the technical difficulties of LPN. Three-dimensional vision, ‘endowrist’ technology, and optical magnification allow excellent vision of the operative field and optimum tissue dissection. These technical characteristics help surgeons to minimize ischaemia-time and facilitate accurate tumour excision. Intra-operative ultrasonography, contrast-enhanced sonography, and photodynamic diagnostics can further improve this procedure. It was already shown that the availability of robotic technology is associated with increased use of PN, and, hence, broader diffusion in routine clinical practice may also provide the possibility to outperform results of open PN, even in more complex cases, and will make minimally invasive PN possible and available for more surgeons and patients. Today, the spread of RAPN is only limited by its availability and the associated financial burden. Hence, LPN will currently be considered a cheaper alternative to RAPN in centres with laparoscopic experience and in those which lack the availability of the robot.

Finally, the study from the Cleveland group and the series by Jain et al. provide some valuable support to the feasibility and safety of repeat RAPN and demonstrate that previously performed PN is not a contraindication for RAPN.

 

Sabine Brookman-May1, Andrea Minervini2, Alessandro Volpe3, Vincenzo Ficarra4, Maciej Salagierski5, Martin Marszalek6,7, Marco Roscigno8, Bülent Akdogan9, Alkuin Vandromme10, Hans Langenhuijsen11, Oscar Rodriguez-Faba12, and Steven Joniau13 for the Renal Cancer Working Group of the Young Academic Urologists (YAU) Working Party of the European Association of Urology (EAU)

1Department of Urology, Ludwig-Maximilians-University, Campus Grosshadern, Munich, Germany, 2Department of Urology, University of Florence, Florence, 3Department of
Urology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, 4Department of Oncological and Surgical Sciences, Urologic Unit, University of Padua, Padua,
Italy, 5Department of Urology, Medical University of Łódź, Łódź, Poland, 6Department of Urology and Andrology, Donauspital, Vienna, and 7Department of Urology, Graz Medical University, Graz, Austria, 8Department of Urology, AO Papa Giovanni XXIII, Bergamo, Italy, 9Department of Urology, Hacettepe University, School of Medicine, Ankara, Turkey, 10Klinik für Urologie und Uroonkologie, Klinikum Braunschweig, Germany, 11Laparoscopy, Robotics and Endourology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, 12Uro-oncology Unit, Fundacio Puigvert, Barcelona, Spain, and 13Department of Urology, University Hospitals Leuven, Leuven, Belgium

 

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Procedure: Robot-assisted laparoscopic PN

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A prospective comparison of surgical and pathological outcomes obtained after robot-assisted or pure laparoscopic partial nephrectomy in moderate to complex renal tumours: results from a French multicentre collaborative study

Alexandra Masson-Lecomte1,2,3, Karim Bensalah5,6, Elise Seringe2,3, Christophe Vaessen1,2, Alexandre de la Taille4,7, Nicolas Doumerc8,9, Pascal Rischmann8,9, Franck Bruyère10,11, Laurent Soustelle12,13, Stéphane Droupy12,13 and Morgan Rouprêt1,2

1Department of Urology, Pitié Salpétrière, Assistance Publique – Hôpitaux de Paris, Paris, 2Université Paris 6, Paris, 3Department of Statistics, Pitié Salpétrière, Assistance Publique – Hôpitaux de Paris, Paris, 4Department of Urology, Henri Mondor, Assistance Publique – Hôpitaux de Paris, Paris, 5Department of Urology, CHU de Reims, Reims, 6Université de Reims Champagnes-Ardenne, Marne, 7Université Paris-Est Creteil, Marne, 8Department of Urology, CHU Rangueil, Toulouse, 9Université Toulouse 3, Toulouse, 10Department of Urology, CHU Bretonneau, Tours, 11Université François-Rabelais, Tours, 12Department of Urology, CHU Caremeau, Nimes, 13Université Montpellier 1, Montpellier, France

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OBJECTIVE

• To prospectively compare the surgical and pathological outcomes obtained with robot-assisted laparoscopic partial nephrectomy (RAPN) or laparoscopic PN (LPN) for renal cell carcinoma in a multicentre cohort.

PATIENTS AND METHODS

• Between 2007 and 2011, 265 nephron-sparing surgeries were performed at six French urology departments. The patients underwent either RAPN (n = 220) or LPN (n = 45) procedures.

• The operative data included operative duration, warm ischaemia time (WIT) and estimated blood loss (EBL). The postoperative outcomes included length of stay (LOS), creatinine variation (Modification of Diet in Renal Disease group), Clavien complications and pathological results.

• The complexity of the renal tumour was classified using the R.E.N.A.L. nephrometry scoring system. Student’s t-test and chi-squared tests were used to compare variables.

RESULTS

• The median follow-ups for the RAPN and LPN groups were 7 and 18 months, respectively (P < 0.001).

• Age and American Society of Anesthesiology score were significantly higher in the LPN group (P = 0.02 and P = 0.004, respectively).

• These variables were lower in the RAPN group: WIT [mean (SD) 20.4 (9.7) vs 24.3 (15.2) min; P = 0.03], operative duration [mean (SD) 168.1 (55.5) vs 199.7 (51.2) min; P < 0.001], operating room occupation time [mean (SD) 248.3 (66.7) vs 278.2 (71.3) min; P = 0.008], EBL [mean (SD) 244.8 (365.4) vs 268.3 (244.9) mL; P = 0.01], use of haemostatic agents [used in 78% of RAPNs and 100% of LPNs; P < 0.001] and LOS [mean (SD) 5.5 (4.3) vs 6.8 (3.2) days; P = 0.05).

• There were no significant differences between pre- and postoperative creatinine levels, pathology report or complication rates between the groups. The main limitation was due to the study’s non-randomised design.

CONCLUSION

• RAPN is not inferior to pure LPN for perioperative outcomes (i.e. EBL, operative duration, WIT, LOS). Only a randomised study with a longer follow-up can now provide further insight into oncological outcomes.

 

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