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Purpose We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event. Materials and Methods Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion. Results The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p <0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p <0.01) and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar location) score (9 vs 8, p <0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96–0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22–1.7, p <0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short-term oncologic outcomes but better renal functional preservation (p <0.01). Conclusions At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion. [ABSTRACT FROM AUTHOR]

Purpose Currently no data exist to guide renal surgeons on the perioperative use of renin-angiotensin blockers despite potential cardiorenal benefits. We aimed to assess the impact of resuming renin-angiotensin blockers on postoperative renal function and adverse cardiac events following partial nephrectomy. Materials and Methods This is an observational analysis of patients who underwent robot-assisted laparoscopic partial nephrectomy from 2006 to 2014 at a single institution. The Wilcoxon rank sum and chi-square tests, and logistic regression were used to assess the risk of adverse renal and cardiac events stratified by history and pattern of renin-angiotensin blockade perioperatively. Results We identified 900 patients with a median followup of 16.3 months (IQR 1.4–39.1). There were no significant differences in severe renal dysfunction at last followup on univariate analysis or adverse cardiac events at 30 days on multivariate analysis in patients stratified by a history of renin-angiotensin blockade. Of the 338 patients 137 (41.9%) resumed renin-angiotensin blockade immediately after surgery, which did not result in any significant difference in the postoperative glomerular filtration rate (p >0.05). Resuming renin-angiotensin blockade at discharge home was associated with a decreased risk of heart failure within 30 days of surgery (0.3% vs 11.8% of cases) and stage IV/V chronic kidney disease at last followup (2.6% vs 25.5%, each p <0.001). Conclusions Renin-angiotensin blockers appear safe to continue immediately after renal surgery. Discharge home with angiotensin converting enzyme inhibitors/angiotensin receptor blockers was associated with a decreased risk of heart failure and severe renal dysfunction. However, this risk may be overstated as a result of the small number of patients discharged without resuming the home medication. [ABSTRACT FROM AUTHOR]

Purpose Cryoablation and radio frequency ablation are attractive modalities for small renal masses in patients with substantial comorbidities. However, salvage extirpative therapy for local recurrence after thermal ablation can be challenging due to associated perinephric fibrosis. Materials and Methods Patients with thermal ablation refractory tumors requiring surgical salvage from 1997 to 2013 were identified and retrospectively reviewed. Results A total of 27 patients were treated surgically after cryoablation (18) or radio frequency ablation (9) failed. Subjective assessment indicated moderate/severe fibrosis in 22 cases (81%). Partial nephrectomy was preferred in all patients but was not possible in 12, primarily due to unfavorable tumor size/location. In the intended partial nephrectomy group (15) open surgery was performed in all patients and completed in 14, with the procedure aborted in 1 due to extensive perinephric fibrosis. Radical nephrectomy was planned in 12 patients, of whom 8 were treated laparoscopically with 1 requiring conversion to open. Median estimated blood loss was 225 ml. Overall 17 patients experienced no complications and 4 had minor complications. However, 6 patients experienced more significant complications (Clavien III-IVb). Since January 2008 partial nephrectomy was performed more frequently (12 of 17, or 71% vs 2 of 10, or 20% for previous cases, p=0.02). Conclusions Surgical salvage after failed thermal ablation is feasible in most instances, and partial nephrectomy is often possible but can be challenging due to associated perinephric fibrosis. The difficulty of surgical salvage should be recognized as a potential limitation of the thermal ablation treatment strategy. Prospective studies of thermal ablation vs partial nephrectomy should be prioritized to provide higher quality data about the merits and limitations of each approach. [ABSTRACT FROM AUTHOR]

Purpose Preservation of renal function is prioritized during surgical management of localized renal cell carcinoma. VEGF targeted agents can downsize tumors in metastatic renal cell carcinoma and may do the same in localized renal cell carcinoma, allowing for optimal preservation of renal parenchyma associated with partial nephrectomy. Materials and Methods Localized clear cell renal cell carcinoma patients meeting 1 or both of the following criteria were enrolled in a prospective phase II trial, including radical or partial nephrectomy likely to yield a glomerular filtration rate of less than 30 ml/minute/1.73 m 2 , or partial nephrectomy high risk due to high complexity (R.E.N.A.L. 10 to 12) or tumor adjacent to hilar vessels. Pazopanib (800 mg once daily) was administered for 8 to 16 weeks with repeat imaging at completion of therapy, followed by surgery. Results A total of 25 patients enrolled with a median tumor size of 7.3 cm and a median R.E.N.A.L. score of 11. Of index lesions 80% were high complexity and 56% of patients had a solitary kidney. Patients received a median of 8 weeks of pazopanib. The median interval from treatment start to surgery was 10.6 weeks. R.E.N.A.L. score decreased in 71% of tumors and 92% of patients experienced a reduction in tumor volume. Six of 13 patients for whom partial nephrectomy was not possible at baseline were able to undergo partial nephrectomy after treatment. The mean parenchymal volume that could be saved with surgery increased from an estimated 107 to 173 cc (p = 0.0015). In 5 patients a urine leak developed, which was managed conservatively, and 7 received a transfusion, of whom 1 required embolization. Conclusions Neoadjuvant pazopanib resulted in downsizing localized renal cell carcinoma, allowing for improved preservation of renal parenchyma and enabling partial nephrectomy in a select subset of patients who would otherwise require radical nephrectomy. [ABSTRACT FROM AUTHOR]

Purpose Chronic kidney disease is associated with a higher likelihood of progression to end stage renal disease and increased mortality rates. However, the etiology of nephron loss may modify the rate of chronic kidney disease progression and overall survival. Materials and Methods Patients with suspected renal malignancy who had a new baseline glomerular filtration rate of less than 60 ml/minute/1.73 m 2 6 weeks after surgery were divided into the 2 groups of surgically induced chronic kidney disease (preoperative glomerular filtration rate greater than 60 ml/minute/1.73 m 2 ) and preexisting chronic kidney disease due to medical causes followed by surgery. An independent cohort of subjects with chronic kidney disease entirely due to medical causes served as a comparator. Results Renal cancer surgery yielded cohorts with surgically induced chronic kidney disease (1,097) and chronic kidney disease due to medical causes followed by surgery (1,053), whereas the group with chronic kidney disease due to medical causes consisted of 42,658 subjects. The patients with chronic kidney disease due to medical causes and chronic kidney disease from medical causes followed by surgery were older compared to those with surgically induced chronic kidney disease, had more medical comorbidities and had a lower baseline glomerular filtration rate (all p <0.001). The group with chronic kidney disease due to medical causes followed by surgery had a lower mean (±SD) new baseline glomerular filtration rate (37±10) compared to the surgically induced chronic kidney disease (48±9) and chronic kidney disease due to medical comorbidities (47±10) groups (p <0.001). The probability of progressive decline in renal function (50% decrease in glomerular filtration rate or need for dialysis) at 3 years was lowest for surgically induced chronic kidney disease, intermediate for chronic kidney disease from medical causes followed by surgery and highest for chronic kidney disease from medical causes when age, gender, race, comorbidities and new baseline glomerular filtration rate were considered (p <0.001). Nonrenal cancer related mortality was substantially lower for those with surgically induced chronic kidney disease compared to the other groups (p <0.001). Conclusions Our data suggest that surgically induced chronic kidney disease has a lower rate of functional decline and less impact on survival than chronic kidney disease due to medical causes. These data have potential implications with respect to chronic kidney disease classification and patient counseling for surgical management of various renal disorders including renal cancer. [ABSTRACT FROM AUTHOR]

Purpose: We evaluated the effect of alvimopan treatment vs placebo on health care utilization and costs related to gastrointestinal recovery in patients treated with radical cystectomy in a randomized, phase 4 clinical trial. Materials and Methods: Resource utilization data were prospectively collected and evaluated by cost consequence analysis. Hospital costs were estimated from 2012 Medicare reimbursement rates and medication wholesale acquisition costs. Differences in base case mean costs between the study cohorts for total postoperative ileus related costs (hospital days, study drug, nasogastric tubes, postoperative ileus related concomitant medication and postoperative ileus related readmissions) and total combined costs (postoperative ileus related, laboratory, electrocardiograms, nonpostoperative ileus related concomitant medication and nonpostoperative ileus related readmission) were evaluated by probabilistic sensitivity analysis using a bootstrap approach. Results: Mean hospital stay was 2.63 days shorter for alvimopan than placebo (mean ± SD 8.44 ± 3.05 vs 11.07 ± 8.23 days, p = 0.005). Use of medications or interventions likely intended to diagnose or manage postoperative ileus was lower for alvimopan than for placebo, eg total parenteral nutrition 10% vs 25% (p = 0.001). Postoperative ileus related health care costs were $2,340 lower for alvimopan and mean total combined costs were decreased by $2,640 per patient for alvimopan vs placebo. Analysis using a 10,000-iteration bootstrap approach showed that the mean difference in postoperative ileus related costs (p = 0.04) but not total combined costs (p = 0.068) was significantly lower for alvimopan than for placebo. Conclusions: In patients treated with radical cystectomy alvimopan decreased hospitalization cost by reducing the health care services associated with postoperative ileus and decreasing the hospital stay. [ABSTRACT FROM AUTHOR]

Purpose: Followup is limited in patients with a solitary kidney who undergo partial nephrectomy. We evaluated overall, cancer specific and recurrence-free survival, and renal function in patients 5 years or greater after open partial nephrectomy. Materials and Methods: We retrospectively reviewed the Cleveland Clinic kidney cancer database, including only patients with a solitary kidney treated with open partial nephrectomy 5 or more years ago (from 1980 to June 2006) who had 6 months or more of followup. Survival and recurrence analyses were calculated using a Cox proportional hazards model. Results are shown as Kaplan-Meier survival curves. Linear regression analysis was done to assess postoperative renal function. Results: A total of 282 patients fit our study inclusion criteria (mean followup 175 months), of whom 233 underwent open partial nephrectomy 10 or more years ago. Actual overall survival was 78.5% and 59.5% at 5 and 10 years, respectivelyThe average estimated glomerular filtration rate at 5 years or greater and 10 years or greater since open partial nephrectomy was 35.1 and 34.5 ml/minute/ 2 1.73 m in 89.7% and 89.6%, respectively, of patients with stage 3 or greater chronic kidney disease. Eight survivors were on intermittent hemodialysis 5 years or more postoperatively, including 5 at 10 years or more. There were 76 recurrences for a calculated 5 and 10-year recurrence-free survival rate of 72% (95% CI 66-879) and 63% (95% CI 57-71), respectively. Conclusions: Open partial nephrectomy in the solitary kidney provides reliable long-term oncological control at 5 and 10 years. Predicted and actual outcomes correspond well. Although most patients have chronic kidney disease postoperatively, it appears stable with minimal progression to dialysis. [ABSTRACT FROM AUTHOR]

Purpose: Chronic kidney disease from medical causes is present in 25% to 30% of patients before surgery for renal cancer. Although chronic kidney disease due to medical causes is typically associated with a 2% to 5% annual renal functional decline and decreased overall survival, reduced glomerular filtration rate occurring only after surgery may not have the same negative consequences. Materials and Methods: All patients undergoing surgery for suspected renal malignancy were identified in an institutional registry. Median clinical followup was 6.6 years. Results: Of 4,180 patients 28% had a preoperative glomerular filtration rate of less than 60 ml/minute/1.73 m2 (chronic kidney disease due to medical causes) and in 22% the glomerular filtration rate decreased to less than 60 ml/minute/1.73 m2 only after surgery (surgically induced chronic kidney disease). Preoperative glomerular filtration rate was a strong predictor of overall survival on univariable and multivariable analysis. The risk of death after renal surgery was 1.8, 3.5 and 4.4-fold higher in patients with preoperative chronic kidney disease stages 3, 4 and 5, respectively, vs normal preoperative glomerular filtration rate. Average overall loss of renal function was 23%, including 13% within 90 days after surgery and 3.5% annually thereafter. Postoperative glomerular filtration rate only predicted survival for patients with preexisting chronic kidney disease due to medical causes. Neither surgically induced chronic kidney disease nor postoperative glomerular filtration rate was a significant predictor of survival in patients without preexisting chronic kidney disease due to medical causes. Annual renal functional decline was 4.7% and 0.7% for patients with chronic kidney disease due to medical causes and surgically induced chronic kidney disease, respectively, with a greater than 50% reduction in glomerular filtration rate in 7.3% and 2.2%, respectively (p <0.0001). Annual renal functional decline greater than 4.0% was associated with a 43% increase in mortality (p <0.0001). Conclusions: Surgically induced chronic kidney disease is associated with a relatively low risk of progressive renal functional decline and impact on survival does not appear to be substantial during intermediate term followup. In contrast, preoperative chronic kidney disease due to medical causes places patients at increased risk, indicating nephron sparing surgery for such patients. [Copyright &y& Elsevier]

Purpose: Renal parenchymal volume decrease after partial nephrectomy is associated with late functional outcomes. We examined the relative effects of resection related and atrophy related volume change on late kidney function. Materials and Methods: Data were analyzed from a cohort of 187 patients who underwent open, laparoscopic or robotic partial nephrectomy between 2009 and 2011. Total change in kidney size after surgery was expressed as percent functional volume preservation measured using the cylindrical volume ratio method. Renal atrophy was expressed as parenchymal thickness preservation, and was assessed by measuring parenchymal thickness before and after partial nephrectomy in regions of the operated kidney distant from the site of resection. Standard statistical analyses were conducted to assess relationships among variables. Results: Mean (± SD) percent functional volume preservation was 92% (±8%), which correlated with a late percent glomerular filtration rate preservation of 91% (±12%). Mean parenchymal thickness preservation for the cohort was 99% (±4%). Minimal atrophy was observed in patients with warm ischemia time less than 40 minutes (parenchymal thickness preservation range 98% to 100%). Atrophy was more pronounced in patients with warm ischemia time greater than 40 minutes (parenchymal thickness preservation 96%). Multivariate regression analysis showed correlation of percent functional volume preservation with atrophy; correlation of warm ischemia time, diameter-axial-polar nephrometry score and atrophy with percent functional volume preservation; and correlation of Charlson score and diameter-axial-polar nephrometry score with percent decrease in glomerular filtration rate. Conclusions: In most patients with warm ischemia time less than 40 minutes the incidence of parenchymal atrophy was minimal, suggesting that the kidney volume decrease after partial nephrectomy was predominantly resection related. Kidney volume decrease after partial nephrectomy in patients with warm ischemia time greater than 40 minutes appeared to be due to a combination of resection related and atrophy related changes. [Copyright &y& Elsevier]

Purpose: We determined the ability of bladder biopsy and transurethral resection of the bladder to accurately predict bladder cancer variants on radical cystectomy since certain variants may affect prognosis and treatment. Materials and Methods: We retrospectively evaluated the records of 302 patients who underwent biopsy and/or transurethral resection of the bladder followed by radical cystectomy from 2008 to 2010. The frequency of variant morphology and the sensitivity of the precystectomy material was determined using pathological findings at radical cystectomy as the final result. Results: Bladder cancer variants were identified in 159 patients (53%) on initial biopsy/transurethral resection and/or final pathological evaluation at radical cystectomy. The most common variant was urothelial carcinoma with squamous differentiation in 72 of 159 patients (45%), followed by micropapillary urothelial carcinoma in 41 (26%). In 9 patients (6%) variant morphology was identified only on biopsy/transurethral resection bladder and not on final radical cystectomy pathological assessment. The remaining 150 patients (94%) showed variant morphology on radical cystectomy with (79 or 53%) or without (71 or 47%) variant morphology on the preceding biopsy/transurethral resection. The sensitivity of variant detection showed a broad range by variant subtype. Overall, initial biopsy/transurethral resection sensitivity was 39% for predicting variant morphology on radical cystectomy. Conclusions: Overall sensitivity for predicting bladder cancer variants from biopsy/transurethral resection of the bladder sampling is relatively low. This is likely due to sampling and tumor heterogeneity rather than to an inaccurate pathological diagnosis. Additional predictive markers of variant morphology may be useful to determine which tumors contain aggressive variants that may alter outcomes or therapy. [ABSTRACT FROM AUTHOR]

Purpose: The R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior) and centrality index nephrometry scores enable systematic, objective assessment of anatomical tumor features. We systematically compared these systems using item analysis test theory to optimize scoring methodology. Materials and Methods: Analysis was based on 299 patients who underwent partial nephrectomy from 2007 to 2011 and met study inclusion criteria. Percent functional volume preservation, and R.E.N.A.L. and centrality index scores were measured. Late percent glomerular filtration rate preservation was calculated as the ratio of the late to the preoperative rate. Interobserver variability analysis was done to assess measurement error. All data were statistically analyzed. Results: A novel scoring method termed DAP (diameter-axial-polar) nephrometry was devised using a data based approach. Mean R.E.N.A.L., centrality index and DAP scores for the cohort were 7.3, 2.5 and 6 with 84%, 90% and 95% interobserver agreement, respectively. The DAP sum score and all individual DAP scoring components were associated with the clinical outcome, including percent functional volume preservation, warm ischemia time and operative blood loss. DAP scoring criteria allowed for the normalization of score distributions and increased discriminatory power. DAP scores showed strong linear associations with percent functional volume preservation (r2 = 0.97) and late percent glomerular filtration rate preservation (r2 = 0.81). Each 1 unit change in DAP score equated to an average 4% change in kidney volume. Conclusions: DAP nephrometry integrates the optimized attributes of the R.E.N.A.L. and centrality index scoring systems. DAP scoring was associated with simplified methodology, decreased measurement error, improved performance characteristics, improved interpretability and a clear association with volume loss and late function after partial nephrectomy. [Copyright &y& Elsevier]

Purpose: Functional volume preservation after partial nephrectomy is a primary determinant of kidney function. We identified tumor features, including R.E.N.A.L. (radius for tumor size as maximal diameter, exophytic/endophytic tumor properties, nearness of deepest portion of tumor to collecting system or sinus, anterior/posterior descriptor and location relative to polar line) and centrality index nephrometry scores, associated with volume loss after partial nephrectomy. Materials and Methods: A chart and imaging review was done for 237 patients who underwent partial nephrectomy from 2007 to 2010 and met study inclusion criteria. R.E.N.A.L. and centrality index nephrometry scores were measured in all patients. Percent functional volume preservation was estimated a median of 1.4 years after surgery using the cylindrical volume ratio method. Statistical analysis was done to study associations. Results: Independent tumor features associated with percent functional volume preservation included tumor diameter (p <0.001) and the distance from tumor periphery to kidney center (p = 0.02). R.E.N.A.L. and centrality index scores were associated with percent functional volume preservation (each p <0.001). Nephrometry scores were also associated with nadir and late percent glomerular filtration rate preservation. Tumors classified as highly complex, with a centrality index score of 1.5 or less and a R.E.N.A.L. score of 10 or greater, were associated with an average 28% to 30% functional parenchymal volume loss of operated kidneys. A mean 8% difference in percent functional volume preservation was observed among low, intermediate and high tumor complexity categories for R.E.N.A.L. and centrality index scores. Conclusions: R.E.N.A.L. and centrality index nephrometry scores were associated with changes in the percent functional volume preservation and the perioperative functional decrease. Nephrometry scores performed better than diameter alone on statistical analysis. Nephrometry scores may be useful to estimate the likelihood of operative volume loss and by proxy the functional outcome. [Copyright &y& Elsevier]

Purpose: We used what is to our knowledge a new method to estimate volume loss after partial nephrectomy to assess the relative contributions of ischemic injury and volume loss on functional outcomes. Materials and Methods: We analyzed the records of 301 consecutive patients who underwent conventional partial nephrectomy between 2007 and 2010 with available data to meet inclusion criteria. Percent functional volume preservation was measured at a median of 1.4 years after surgery. Modification of diet in renal disease-2 estimated glomerular filtration rate was measured preoperatively and perioperatively, and a median of 1.2 years postoperatively. Statistical analysis was done to study associations. Results: Hypothermia or warm ischemia 25 minutes or less was applied in 75% of cases. Median percent functional volume preservation was 91% (range 38%–107%). Percent glomerular filtration rate preservation at nadir and late time points was 77% and 90% of preoperative glomerular filtration rate, respectively. On multivariate analysis percent functional volume preservation and warm ischemia time were associated with nadir glomerular filtration rate while only percent functional volume preservation was associated with late glomerular filtration rate (each p <0.001). Late percent glomerular filtration rate preservation and percent functional volume preservation were directly associated (p <0.001). Recovery of function to 90% or greater of percent functional volume preservation predicted levels was observed in 86% of patients. In patients with de novo postoperative stage 3 or greater chronic kidney disease, percent functional volume preservation and Charlson score were associated with late percent glomerular filtration rate preservation. Warm ischemia time was not associated with late functional glomerular filtration rate decreases in patients considered high risk for ischemic injury. Conclusions: In this cohort volume loss and not ischemia time was the primary determinant of ultimate renal function after partial nephrectomy. Technical modifications aimed at minimizing volume loss during partial nephrectomy while still achieving negative margins may result in improved functional outcomes. [Copyright &y& Elsevier]

Purpose: We investigated the effect of sunitinib on locally advanced primary renal carcinoma tumors and the ability to facilitate subsequent surgery. Materials and Methods: Patients with an unresectable primary renal tumor, with or without distant metastases, received 50 mg sunitinib with continuous daily dosing in a phase II trial. Computerized tomography was performed every 12 weeks to determine surgical resectability. The primary end point of the trial was the percentage of patients with renal cell carcinoma and initially unresectable primary tumors who could undergo nephrectomy after sunitinib therapy. Results: Of 30 patients enrolled in the study (19 with distant metastases) 28 (35 total renal tumors) were evaluable for response. The median change in primary renal cell carcinoma tumors was a 22% decrease, corresponding to a median absolute reduction of 1.2 cm. The median reduction in primary renal cell carcinoma tumors of clear cell histology was −28% (absolute reduction 1.7 cm) compared to a 1.4% increase (0.1 cm absolute increase) in nonclear cell tumors. Of these patients 13 (45%) met the primary end point of being able to undergo nephrectomy after preoperative sunitinib. All patients had viable renal cell carcinoma in the surgical specimen and surgical morbidity was consistent with prior experience of nephrectomy in patients without preoperative therapy. Conclusions: Sunitinib as initial therapy in patients with locally advanced features of the primary tumor was feasible and resulted in an antitumor effect that enabled subsequent surgery in a subset of patients. Further prospective study is required to refine the most suitable application of this approach. [Copyright &y& Elsevier]

Purpose: We evaluated the incidence of positive lymph nodes in the presacral and retroperitoneal regions in patients who underwent radical cystectomy and extended pelvic lymph node dissection for urothelial bladder cancer. Materials and Methods: As part of a prospective mapping study, 143 patients underwent radical cystectomy and extended pelvic lymph node dissection for urothelial bladder cancer between 2006 and 2010. Lymph nodes from 6 separate regions were labeled, including bilateral pelvic and common iliac, presacral and retroperitoneal. We evaluated pathological features, treatment outcomes and cancer specific survival in patients with or without lymph node positive disease in the presacral and retroperitoneal regions. Results: A median of 37 lymph nodes (IQR 27–49) were removed. Overall 52 (36%) patients had positive lymph nodes, of whom 24 (46%) had metastatic disease in the presacral or retroperitoneal region. Four patients (3%) had an isolated solitary positive lymph node in these 2 templates. Two-year overall survival in patients without vs with presacral/retroperitoneal lymph node positive disease was 44% (95% CI 24–64) vs 25% (95% CI 5–45) (p = 0.11). In contrast, 2-year cancer specific survival in the 2 groups was 55% (95% CI 33–77) and 29% (95% CI 7–51), respectively (p = 0.02). Conclusions: A substantial proportion of patients have lymph node positive disease in the presacral and retroperitoneal regions, including some with isolated and/or solitary lymph node involvement. While the limited positive lymph node burden in these templates suggests a potential therapeutic role for extending the anatomical boundaries of lymph node dissection, patient survival was poor. Extended lymph node dissection provides important staging information but to our knowledge the therapeutic benefit has yet to be definitively proved. [Copyright &y& Elsevier]

Purpose: The percent of functional volume preservation is a primary determinant of functional outcome after partial nephrectomy. We assessed what is to our knowledge a novel method to estimate the percent of functional volume preservation to assess its effect on functional outcomes. Materials and Methods: We studied the glomerular filtration rate outcome based on the modification of diet in renal disease 2 in 39 patients with normal preoperative serum creatinine who underwent open or laparoscopic partial nephrectomy from January 2007 to December 2009. A cylindrical volume ratio method was used to estimate the percent of functional volume preservation on computerized tomography images obtained before and after partial nephrectomy. A model to predict the postoperative estimated glomerular filtration rate was based on multiplying the preoperative glomerular filtration rate by the percent of functional volume preservation, followed by adjustment for the functional contribution of the contralateral kidney. Correlation and multiple regression analysis was done to test the model. Results: The median preoperative, nadir and late estimated glomerular filtration rate in the cohort was 104 (range 53 to 234), 75 (range 21 to 189) and 90 ml per minute/1.73 m2 (range 45 to 228), respectively. The nadir and late estimated glomerular filtration rate was measured at a median of 2 (range 0 to 8) and 358 days (range 13 to 827), respectively. The median percent of functional volume preservation was 88% (range 50% to 100%) for the operated kidney and 94% (range 75% to 105%) when adjusted for total bilateral kidney volume. We noted a 96% correlation between the predicted and the observed late estimated glomerular filtration rate. On multivariate analysis the preoperative glomerular filtration rate (p <0.001) and ischemia time (p = 0.02) correlated with the nadir glomerular filtration rate, and the preoperative glomerular filtration rate (p <0.001) and the percent of functional volume preservation (p = 0.04) correlated with the late glomerular filtration rate. Conclusions: These data support the notion that preoperative nephron endowment and the percent of functional volume preservation are the primary determinants of the long-term functional outcome after partial nephrectomy in patients with normal preoperative kidney function who have ischemia time within acceptable limits. [Copyright &y& Elsevier]

Purpose: Ischemic damage during partial nephrectomy increases with each minute of warm ischemia, leading some groups to advocate hypothermia in all cases or partial nephrectomy without vascular occlusion as a primary technique. The renal functional implications of these approaches have not been well studied in patients who undergo elective partial nephrectomy. Materials and Methods: We evaluated early and late renal functional outcomes in 1,132 patients with 2 functioning kidneys and normal preoperative serum creatinine who underwent partial nephrectomy without regional ischemia (58), with less than 30-minute warm ischemia (809) or with cold ischemia (265). Results: The preoperative, postoperative and latest glomerular filtration rates were not significantly different in the 3 groups. At latest followup the relative decrease in renal function was less in cases without regional ischemia than in those with less than 30-minute warm ischemia and those with cold ischemia (0.5% vs 13% and 11%, respectively, p <0.001). In part this reflected selection bias since tumor size and the amount of parenchyma removed were lowest in that group (p <0.001). On multivariate analysis the percent of parenchyma preserved and the baseline glomerular filtration rate were strongly associated with the postoperative and latest glomerular filtration rates (p <0.001) but the partial nephrectomy approach was not (p >0.05). Adverse short or long-term renal functional outcomes were marginally increased in patients with 20 to 30-minute warm ischemia. However, such events were uncommon and renal failure developed in only 4 of 1,132 patients (less than 0.4%). Conclusions: During elective partial nephrectomy a warm ischemia time of less than 20 minutes is not associated with clinically relevant functional loss compared to that of alternative techniques. However, longer warm ischemia time may correlate with ischemic injury and should be avoided. [ABSTRACT FROM AUTHOR]

Purpose: Factors that determine renal function after partial nephrectomy are not well- defined, including the impact of cold vs warm ischemia, and the relative importance of modifiable and nonmodifiable factors. We studied these determinants in a large cohort of patients with a solitary functioning kidney undergoing partial nephrectomy. Materials and Methods: From 1980 to 2009, 660 partial nephrectomies were performed at 4 centers for tumor in a solitary functioning kidney under cold (300) or warm (360) ischemia. Data were collected in institutional review board approved registries and followup averaged 4.5 years. Preoperative and postoperative glomerular filtration rates were estimated via the Chronic Kidney Disease-Epidemiology Study equation. Results: At 3 months after partial nephrectomy median glomerular filtration rate decreased by equivalent amounts with cold or warm ischemia (21% vs 22%, respectively, p = 0.7), although median cold ischemic times were much longer (45 vs 22 minutes respectively, p <0.001). On multivariable analyses increasing age, larger tumor size, lower preoperative glomerular filtration rate and longer ischemia time were associated with decreased postoperative glomerular filtration rate (p <0.05). When percentage of parenchyma spared was incorporated into the analysis, this factor and preoperative glomerular filtration rate proved to be the primary determinants of ultimate renal function, and duration of ischemia lost statistical significance. Conclusions: This nonrandomized, comparative study suggests that within the relatively strict parameters of conventional practice, ie predominantly short ischemic intervals and liberal use of hypothermia, ischemia time was not an independent predictor of ultimate renal function after partial nephrectomy. Long-term renal function after partial nephrectomy is determined primarily by the quantity and quality of renal parenchyma preserved, although type and duration of ischemia remain the most important modifiable factors, and warrant further study. [Copyright &y& Elsevier]

Purpose: Partial nephrectomy is now a standard of care for clinical stage T1 renal cancers amenable to a nephron sparing approach. Based on tumor size and location, some partial nephrectomies can be more challenging and necessitate longer ischemic intervals, and radical nephrectomy is considered an alternative standard of care for these tumors. We evaluate whether partial nephrectomy with extended ischemia provides improved renal functional outcomes compared with radical nephrectomy. Materials and Methods: Renal functional outcomes were analyzed in 2,402 consecutive patients with serum creatinine 1.4 mg/dl or less and 2 functioning kidneys treated for cT1 renal cancer at Cleveland Clinic with partial (1,833, 76%) or radical nephrectomy (569, 24%). Patients treated with partial nephrectomy were grouped according to duration of ischemia using the categories of limited (less than 30 minutes), unknown or extended (greater than 30 minutes). Results: Patients in all 4 groups had similar preoperative creatinine (median 0.9 mg/dl) and estimated glomerular filtration rate (median 82 to 84 ml/minute/1.73 m2). Patients undergoing radical nephrectomy on average were older, and had more comorbidities and larger tumors (p <0.001). Regardless of type of surgery, this cohort as a whole was at low risk (less than 1%) for renal failure (estimated glomerular filtration rate less than 15 ml/minute/1.73 m2). However, patients in the radical nephrectomy cohort were far more likely (p <0.001) to have an estimated glomerular filtration rate less than 45 ml/minute/1.73 m2 (35%) than any of the partial nephrectomy groups (limited 11%, unknown 15%, extended ischemia 19%). Conclusions: Even when performed with extended ischemia, partial nephrectomy is associated with renal functional outcomes superior to those of radical nephrectomy for clinical stage T1 renal cancers. Partial nephrectomy should be considered even for tumors in which anticipated ischemia may exceed 30 minutes. [Copyright &y& Elsevier]

Purpose: Radical nephrectomy has traditionally been preferred to partial nephrectomy in patients with localized renal cell cancer because of its simplicity and established cancer control. Recent data suggest that these patients have significant competing risks of death, some of which may be increased by chronic renal insufficiency. Therefore, we compared overall survival, cancer specific survival and cardiac specific survival in patients undergoing partial or radical nephrectomy for cT1b tumors. Materials and Methods: From 1999 to 2006, 1,004 patients with renal masses between 4 and 7 cm underwent extirpative surgery, partial nephrectomy (524) or radical nephrectomy (480). We generated a propensity model based on preoperative patient characteristics, and then modeled survival with the additional variables of pathological stage and new baseline renal function. Results: On multivariate analysis cancer specific survival was equivalent for patients treated with partial nephrectomy or radical nephrectomy. Those patients undergoing radical nephrectomy lost significantly more renal function than those undergoing partial nephrectomy. The average excess loss of renal function observed with radical nephrectomy was associated with a 25% (95% CI 3–73) increased risk of cardiac death and 17% (95% CI 12–27) increased risk of death from any cause on multivariate analysis. Conclusions: Partial nephrectomy offers cancer specific survival equivalent to that of radical nephrectomy and is technically feasible in at least 50% of patients with cT1b tumors. Preservation of renal function was significantly better in patients treated with partial nephrectomy. Postoperative renal insufficiency was a significant independent predictor of overall and cardiovascular specific survival, and efforts should be made to limit the renal function loss associated with surgery for localized renal masses. [Copyright &y& Elsevier]

Purpose: Ureteral replacement with interposition of a bowel segment has traditionally required a large incision with substantial associated morbidity and prolonged time to convalescence. During the last 7 years a technique for laparoscopic assisted ileal interposition has evolved that mimics our open approach. We present a comparative analysis of functional and perioperative outcomes between patients undergoing laparoscopic or open ileal ureter replacement at our institution. Materials and Methods: A search of all procedures from 1980 to the present revealed 7 patients undergoing laparoscopic and 7 undergoing open ileal interposition. Functional and perioperative data from these patients are compared, and a detailed description of technique for the laparoscopic procedure is presented. Results: Narcotic analgesic use in morphine equivalents (median 38.9 vs 322.2 mg, p = 0.035) and time to convalescence (median 4 vs 5.5 weeks, p = 0.03) were significantly less in the laparoscopic group. A trend toward shorter hospital stay (median 5 vs 8 days, p = 0.101) was also noted in patients in the laparoscopic group. There was no evidence of anastomotic stricture for patients in either group at last followup. Conclusions: Despite the small number of subjects involved a significant advantage was noted for postoperative recovery after laparoscopic compared to open ileal interposition. A detailed understanding of this complicated procedure can help prevent inherent pitfalls. [Copyright &y& Elsevier]

Purpose: The development of targeted agents for renal cell carcinoma has renewed interest in consolidative surgery due to the robust clinical responses seen with these agents. The integration of targeted therapy and surgery requires careful consideration due to the potential for increased perioperative morbidity. Materials and Methods: We retrospectively identified patients with renal cell carcinoma treated with sunitinib, sorafenib or bevacizumab plus interleukin-2 before tumor resection. Results: Between June 2005 and August 2008, 19 patients were treated with targeted therapy and subsequently underwent resection. Surgical extirpation involved an open and a laparoscopic approach in 18 and 3 cases, respectively, for locally advanced (8), locally recurrent (6) and metastatic disease (3). Two patients with extensive bilateral renal cell carcinoma were also treated to downsize the tumors to enable partial nephrectomy. Perioperative complications were noted in 16% of patients. One patient had a significant intraoperative hemorrhage and disseminated intravascular coagulopathy from a concomitant liver resection. An anastomotic bowel leak and abscess were noted postoperatively in another patient who underwent en bloc resection of a retroperitoneal recurrence and adjacent colon. Two patients (11%) had minor wound complications, including a wound seroma and a ventral hernia. Pathological analysis of 20 specimens revealed clear cell, chromophobe and unclassified renal cell carcinoma in 80%, 5% and 10% of cases, respectively. One patient (5%) had a pathological complete response. Conclusions: Surgical resection of renal cell carcinoma after targeted therapy is feasible with low morbidity in most patients. However, significant complications can occur, raising concern for possible compromise of tissue and/or vascular integrity associated with surgery in this setting. [Copyright &y& Elsevier]

Purpose: Nephron sparing surgery is an increasingly used alternative to Robson''s radical nephroadrenalectomy. The indications for adrenalectomy in patients undergoing partial nephrectomy are not clearly defined and some surgeons perform it routinely for large and/or upper pole renal tumors. We analyzed initial management and oncological outcomes of adrenal glands after open partial nephrectomy. Materials and Methods: Institutional review board approval was obtained for this study. During partial nephrectomy the ipsilateral adrenal gland was resected if a suspicious adrenal nodule was noted on radiographic imaging, or if intraoperative findings indicated direct extension or metastasis. Results: Concomitant adrenalectomy was performed in 48 of 2,065 partial nephrectomies (2.3%). Pathological analysis revealed direct invasion of the adrenal gland by renal cell carcinoma (1), renal cell carcinoma metastasis (2), other adrenal neoplasms (3) or benign tissue (42, 87%). During a median followup of 5.5 years only 15 patients underwent subsequent adrenalectomy (0.74%). Metachronous adrenalectomy was ipsilateral (10), contralateral (2) or bilateral (3), revealing metastatic renal cell carcinoma in 11 patients. Overall survival at 5 years in patients undergoing partial nephrectomy with or without adrenalectomy was 82% and 85%, respectively (p = 0.56). Conclusions: Adrenalectomy should not be routinely performed during partial nephrectomy, even for upper pole tumors. We propose concomitant adrenalectomy only if a suspicious adrenal lesion is identified radiographically or invasion of the adrenal gland is suspected intraoperatively. Using these criteria adrenalectomy was avoided in more than 97% of patients undergoing partial nephrectomy. Even using such strict criteria only 13% of these suspicious adrenal nodules contained cancer. The rarity of metachronous adrenal metastasis and the lack of an observable benefit to concomitant adrenalectomy support adrenal preservation during partial nephrectomy except as previously outlined. [Copyright &y& Elsevier]

Purpose: We report our experience with patients requiring long-term anticoagulation therapy who underwent open or laparoscopic partial nephrectomy for renal tumors at our institution. We compared outcomes with those in a control group undergoing partial nephrectomy with no anticoagulation requirements. Materials and Methods: We retrospectively reviewed the records of 1,031 patients who underwent laparoscopic or open partial nephrectomy from 2000 to 2005. Since 2000, 31 open and 16 laparoscopic partial nephrectomies were performed in patients on chronic warfarin, clopidogrel or cilostazol. Anticoagulation was appropriately discontinued perioperatively. The 47 anticoagulated cases were compared with 47 nonanticoagulated controls that were carefully matched for surgical approach, partial nephrectomy defect size, tumor size and location, procedure year and warm ischemia time. Investigators were blinded to all clinical outcomes throughout the matching process. Bleeding and thrombotic outcomes were then analyzed. Results: The 2 groups were well matched for resection bed size, tumor size, tumor location (central vs peripheral), solitary kidney, operative time and warm ischemia time (each p ≥0.3). Controls had significantly higher intraoperative blood loss (300 vs 200, p <0.05) and a greater postoperative decrease in hemoglobin (3.5 vs 2.4 mg/dl, p <0.001). However, transfusion rates were similar in the 2 groups (each 15%). Five patients on anticoagulation had thrombotic events postoperatively vs none in the control group. Conclusions: Patients on anticoagulation are at higher perioperative risk but with careful perioperative management of anticoagulation therapy partial nephrectomy can be performed in a safe and efficacious manner. To our knowledge this is the largest study of outcomes in this complex patient population. [Copyright &y& Elsevier]

Purpose: With the advent of minimally invasive, nephron sparing surgical options we hypothesized that the indications, perioperative parameters and complication rates of open partial nephrectomy may have changed significantly during a 10-year period. Materials and Methods: Open partial nephrectomy was compared during 2, 3-year periods. From 1994 to 1996 (before laparoscopic partial nephrectomy, cryoablation and radio frequency ablation) 208 cases were compared vs 347 open partial nephrectomies performed from 2004 to 2006 with regard to indications, perioperative parameters and complication rates. Results: There were no significant differences between the groups with regard to age (59 vs 58 years), gender (65.5% vs 65.0% male) and tumor size (3.9 vs 3.6 cm). Tumors removed in the recent era were more often in a solitary kidney (40.0% vs 15.6%) and centrally located (55.6% vs 37.3%), and pathological evaluation more often revealed higher grade (Fuhrman 3 or 4) (43.1% vs 27.8%, each p <0.0001). Despite increased technical difficulty ischemia time in the more recent era was shorter (19.1 vs 40.6 minutes, p = 0.0000), and the urological and overall complication rates were statistically similar (7.5% vs 8.9%, p = 0.6071 and 19.1% vs 14.4%, p = 0.1723, respectively). Conclusions: At a tertiary referral center the introduction of minimally invasive, nephron sparing surgical techniques has drawn away less complicated, less aggressive tumors, reserving the bulk of more complicated central tumors for open partial nephrectomy without decreasing the total number of open cases. With experience these more difficult central tumors are being successfully treated with decreased warm ischemia time and complication rates that are comparable to those in historical series. [Copyright &y& Elsevier]

Purpose: We compared the postoperative and renal functional outcomes of patients undergoing open or laparoscopic partial nephrectomy for tumor in a solitary functioning kidney. Materials and Methods: Between 1999 and 2006, 169 open and 30 laparoscopic partial nephrectomies were performed for 7 cm or smaller tumors in a solitary functioning kidney. Data were collected in an institutional review board approved registry and median followup was 2.0 years. Preoperative and postoperative glomerular filtration rates were estimated with the abbreviated Modification of Diet in Renal Disease equation. Results: By 3 months after open or laparoscopic partial nephrectomy, the glomerular filtration rate decreased by 21% or 28%, respectively (p = 0.24). Postoperative dialysis was required acutely after 1 open partial nephrectomy (0.6%) and 3 laparoscopic partial nephrectomies (10%, p = 0.01), and dialysis dependent end stage renal failure within 1 year occurred after 1 open partial nephrectomy (0.6%) and 2 laparoscopic partial nephrectomies (6.6%, p = 0.06). In multivariate analysis warm ischemia time was 9 minutes longer (p <0.0001) and the chance of postoperative complications was 2.54-fold higher (p <0.05) with laparoscopic partial nephrectomy. Longer warm ischemia time (more than 20 minutes) and preoperative glomerular filtration rate were associated with poorer postoperative glomerular filtration rate in multivariate analysis. Notwithstanding the association with warm ischemia time, the surgical approach itself was not an independent predictor of postoperative glomerular filtration rate (p = 0.77). Conclusions: While laparoscopic partial nephrectomy is technically feasible for tumor in a solitary kidney, warm ischemia time was longer and complication rates higher compared with open partial nephrectomy. In addition, although average loss of renal function at 3 months is equivalent (after accounting for warm ischemia time), a greater proportion of patients required dialysis temporarily or permanently after laparoscopic partial nephrectomy in this initial series. Therefore, open partial nephrectomy may be the preferred nephron sparing approach at this time for these patients at high risk for chronic kidney disease. [Copyright &y& Elsevier]

Purpose: We determined the incidence of and risk factors for perioperative complications associated with laparoscopic oncological surgery for urological malignancy. Materials and Methods: All records of patients undergoing laparoscopic surgery for urological malignancy at a tertiary care institution from April 1997 through January 2006 were reviewed. Relevant demographic and perioperative data during and within 6 weeks of surgery were evaluated retrospectively. Various factors were analyzed to estimate risk of a perioperative complication such as the Charlson Comorbidity Index, American Society of Anesthesiologists score, European Scoring System for laparoscopic urological operations and surgeon experience. Logistic regression was used to identify independent risk factors for perioperative complications. Results: A total of 1,867 laparoscopic oncological surgeries were performed, including radical or partial nephrectomy, nephroureterectomy, radical prostatectomy and radical cystectomy. Perioperative complications occurred in 12.4% of patients, including 3.5% intraoperatively and 8.9% postoperatively. Intraoperative (2.3%) and postoperative hemorrhage (2.7%) accounted for 40% of all perioperative complications. All cause perioperative mortality occurred in 8 patients (0.4%). On multivariate analysis radical cystectomy (adjusted OR 4.9, p <0.001), partial nephrectomy (adjusted OR 2.4, p <0.001), length of surgery greater than 4 hours (adjusted OR 2.5, p <0.001) and preoperative serum creatinine greater than 1.5 mg/dl (adjusted OR 2.1, p = 0.04) were independent risk factors for perioperative complications. Comparing the periods of 1997 to 2000 vs 2001 to 2005, despite a significant increase in technical complexity of procedures (European Scoring System 9.8 vs 60.6, p <0.001), the incidence of complications tended to decrease (17.3% vs 12.5%, p = 0.3). Conclusions: In appropriately selected patients laparoscopic urological oncological surgery is safe. These data on perioperative complications could possibly serve as a reference benchmark for practicing urologists. [Copyright &y& Elsevier]

Purpose: The safe duration of ischemia during nephron sparing surgery remains controversial. We performed a multi-institutional study to evaluate the renal effects of vascular clamping in patients with solitary kidneys. Materials and Methods: Using the Cleveland Clinic and Mayo Clinic databases, we identified 537 patients with solitary kidneys who underwent open nephron sparing surgery. Renal complications were compared among patients who did not require vascular clamping (85), and those who had warm ischemia (174) and cold ischemia (278). Results: Median patient age (63, 65, 64 years) and preoperative creatinine (1.4, 1.3, 1.4 mg/dl) were similar among patients with no ischemia, warm ischemia and cold ischemia, respectively. Median tumor size was smaller in patients with no ischemia (2.5 cm), compared to patients with warm (3.5 cm) and cold (4.0 cm) ischemia (p <0.001). Warm and cold ischemia was associated with a significantly increased risk of urine leak (p = 0.006), acute (p <0.001) and chronic (p = 0.027) renal failure, and temporary dialysis (p = 0.028) compared to patients with no ischemia. Warm ischemia longer than 20 minutes and cold ischemia longer than 35 minutes were associated with a higher incidence of acute renal failure (p = 0.002 and p = 0.003, respectively). Additionally, warm ischemia more than 20 minutes was associated with an increased risk of chronic renal insufficiency (41% vs 19%, p = 0.008), increase in creatinine greater than 0.5 (42% vs 15%, p <0.001) and permanent dialysis (10% vs 4%, p = 0.145). Conclusions: Vascular clamping during open nephron sparing surgery is associated with a higher incidence of renal complications. Attempts to limit warm ischemia to 20 minutes and cold ischemia to 35 minutes should be used when vascular clamping is necessary. [Copyright &y& Elsevier]

Purpose: We present a series of 400 patients with tumor in a solitary kidney who underwent open surgical partial nephrectomy performed by a single surgeon (ACN) with a primary focus on postoperative long-term kidney function. Materials and Methods: A total of 400 patients with sporadic nonfamilial kidney tumors in a solitary kidney underwent open partial nephrectomy between 1980 and 2002. In 323 patients (81%) the contralateral kidney had been surgically removed, while the remaining 77 (19%) had a congenital solitary kidney. Renal insufficiency was present preoperatively in 184 patients (46%). Adverse risk factors for partial nephrectomy were present in a large percent of patients. Intraoperative and postoperative parameters were evaluated at a mean followup of 44 months. Results: In the overall series 5 and 10-year cancer specific survival was 89% and 82%, respectively. Surgical complications occurred in 52 patients (13%), most commonly urinary leakage. Early postoperative renal function was achieved in 398 patients (99.5%). Only 2 patients required permanent dialysis postoperatively. Satisfactory long-term renal function was achieved in 382 patients (95.5%). A total of 18 patients had progressed to renal failure a mean of 3.6 years after surgery. Patient age, the amount of renal parenchyma resected, a congenitally absent or atrophic contralateral kidney and the time of contralateral nephrectomy were noted to be significantly associated with postoperative renal function. Conclusions: Open surgical partial nephrectomy can be safely performed in patients with tumor in a solitary kidney. Long-term cancer-free survival with the preservation of renal function can be reliably expected in most of these cases. [Copyright &y& Elsevier]