WCE 2018: Is There A Benefit To Partial Nephrectomy In High Complexity Tumors Over Radical Nephrectomy: A Multi-Institutional Analysis of Outcomes

Paris, France (UroToday.com) The surgical treatment options of complex renal tumors has constantly been debated in the academic urological community. Particularly, the decision on whether to fully excise the kidney with a radical nephrectomy versus a more kidney sparing approach with a partial nephrectomy has puzzled urologists who want the greatest level of care for their patients. Dr. Alp Tuna Beksac and his team from the Icahn School of Medicine at Mount Sinai, New York is one such group that understood this dilemma and took matters into their own hands by researching and reporting their findings on the operative outcomes of radical nephrectomy (RN) versus partial nephrectomy (PN) in high complexity tumor cases. As such, Dr. Beksac began his presentation by reiterating these points, then proceeded by explaining his research study in which the safety and efficacy of PN for patients with high nephrometry score tumors was analyzed and compared with RN.

To properly answer this intriguing question, the researchers organized a multi-institutional, retrospective kidney cancer database where patients with a cT1-cT2a renal mass were treated with a RN or PN were identified. Of note, patients with end-stage renal disease or metastatic disease were excluded from analyses. Additionally, PN patients were used only if their R.E.N.A.L. nephrometry score was ≥ 10. The data points recorded within this data repository included perioperative outcomes, renal function, recurrence, and overall survival. Following the data collection process, 267 patients who underwent RN and 198 patients who underwent PN were identified. Of note, there was a significant increase in both patient age and tumor size in the RN cohort compared to the PN cohort.

After multivariable analyses were completed, adjusted for confounding variables, it was shown that RN was associated with a 78 minute reduction in operative time, a statistically significant data point when compared to PN. Additionally, there was a 51% reduction in blood loss and a 76% reduction in the odds of a positive surgical margin. It was also shown that 7% of PN cases were converted to RN intraoperatively. Though these previously mentioned data seem to favor the RN modality, it was shown that RN was associated with a greater linear decline in estimated glomerular filtration rate (eGFR) over time (Figure 1) and a six times higher likelihood of acute kidney injury (>25% reduction in eGFR) at discharge. There was no statistically significant differences in length of stay, complication rate, transfusion rate, recurrence, or overall survival between the two groups.

(Figure 1: Estimated glomerular filtration rate (eGFR) over time between the radical nephrectomy and partial nephrectomy cohorts)

As Dr. Beksac concluded his presentation, he discussed with the audience the implications of both PN and RN for the treatment of complex renal tumors. He described that the PN technique was associated with superior functional outcomes without an increase in complication or transfusion rates. Though PN did have a greater operative time and higher estimated blood loss, he believes that PN is the safest option to treat patients with high nephrometry scored tumors.

Presented by: Dr. Alp Tuna Beksac
David Paulucci¹, Ronney Abaza², Daniel D. Eun³, Akshay Bhandari⁴, Ashok K. Hemal⁵, James Porter⁶, Ketan Badani¹

Affiliations: ¹Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; ²Robotic Urology Surgery, OhioHealth Dublin Methodist Hospital, Columbus, OH, USA; ³Department of Urology, Temple University School of Medicine, Philadelphia, PA, USA; ⁴Division of Urology, Columbia University at Mount Sinai, Miami Beach, FL, USA; ⁵Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA; ⁶Swedish Urology Group, Seattle, WA, USA

Written by: Zachary Valley, Department of Urology, University of California-Irvine medical writer for UroToday at the 36th World Congress of Endourology (WCE) and SWL - September 20-23, 2018 Paris, France

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