Publications by authors named "Ithaar Derweesh"

205 Publications

Single stage Xi® robotic radical nephroureterectomy for upper tract urothelial carcinoma: surgical technique and outcomes.

Minerva Urol Nephrol 2021 Mar 29. Epub 2021 Mar 29.

Division of Urology, VCU Health System, Richmond, VA, USA -

Background: Radical nephroureterectomy (RNU) represents the standard of care for high grade upper tract urothelial carcinoma (UTUC). Open and laparoscopic approaches are well-established treatments, but evidence regarding robotic RANU is growing. The introduction of the Xi® system facilitates the implementation of this multi-quadrant procedure. The aim of this video-article is to describe the surgical steps and the outcomes of Xi® robotic RNU.

Methods: Single stage Xi® robotic RNU without patients repositioning and robot re-docking were done between 2015 and 2019 and collected in a large worldwide multi-institutional study, the ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST). Institutional review board approval and data share agreement were obtained at each center. Surgical technique is described in detail in the accompanying video. Descriptive statistics of baseline characteristics and surgical, pathological, and oncological outcomes were analyzed. RESULTSː Overall, 148 patients were included in the analysis; 14% had an ECOG >1 and 68.2% ASA ≥3. Median tumor dimension was 3.0 (IQR:2.0-4.2) cm and 34.5% showed hydronephrosis at diagnosis. Forty-eight% were cT1 tumors. Bladder cuff excision and lymph node dissection were performed in 96% and 38.1% of the procedures, respectively. Median operative time and estimated blood loss were 215.5 (IQR:160.5-290.0) minutes and 100.0 (IQR: 50.0-150.0) mL, respectively. Approximately 56% of patients took opioids during hospital stay for a total morphine equivalent dose of 22.9 (IQR:16.0-60.0) milligrams equivalent. Postoperative complications were 26 (17.7%), with 4 major (15.4%). Seven patients underwent adjuvant chemotherapy, with median number of cycles of 4.0 (IQR:3.0-6.0).

Conclusions: Single stage Xi® RNU is a reproducible and safe minimally invasive procedure for treatment of UTUC. Additional potential advantages of the robot might be a wider implementation of LND with a minimally invasive approach.
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http://dx.doi.org/10.23736/S2724-6051.21.04247-8DOI Listing
March 2021

Preoperative Elevation of C-Reactive Protein Is a Predictor for Adverse Oncologic Survival Outcomes for Renal Cell Carcinoma: Analysis from the International Marker Consortium Renal Cancer (INMARC).

Clin Genitourin Cancer 2021 Feb 18. Epub 2021 Feb 18.

Department of Urology and Winship Cancer Institute, Emory University, Atlanta, Georgia. Electronic address:

Background: We sought to analyze the usefulness of pretreatment C-reactive protein (CRP) as a predictor of survival and oncological outcomes in patients with renal cell carcinoma (RCC).

Methods: Retrospective international analysis of patients with RCC with pretreatment CRP values from 2006 to 2017. A CRP of more than >5 mg/L was deemed elevated. The cohort was subdivided into 2 groups for analysis (normal CRP ≤5 mg/L; elevated CRP >5). Primary outcome was overall survival (OS) and secondary outcome was recurrence-free survival (RFS). Kaplan-Meier analyses (KMA) and multivariable analyses (MVA) were used to delineate survival outcomes and their predictors.

Results: We analyzed 2445 patients (1641 male/804 female; normal CRP 1056/elevated CRP 1389; mean follow-up 36 months). Patients with elevated CRP had a higher incidence of hypertension (P = .001), higher body mass index (P < .001), and larger tumor size (6.0 cm vs 3.9 cm; P < .001). MVA for RFS demonstrated elevated CRP (hazard ratio [HR], 1.85; P = .005), tumor size (HR, 1.1; P < .001), and high tumor grade (HR, 3.1; P < .001) to be independent risk factors. For normal vs elevated CRP, KMA for RFS of stages 1-4 RCC revealed a 5-year RFS of 93% vs 88% (P = .001), 95% vs 83% (P = .163), 84% vs 62% (P = .001), and 58% vs 60% (P = .513), respectively. KMA MA KMA for OS of stages 1-4 RCC revealed a 5-year OS of 98% vs 81% (P = .001), 94% vs 80% (P = .103), 94% vs 65% (P = .001), and 99% vs 38% (P < .001), respectively.

Conclusions: Pretreatment CRP was an independent predictor of RFS and OS in an international multicenter cohort of patients with RCC.
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http://dx.doi.org/10.1016/j.clgc.2021.02.003DOI Listing
February 2021

A Preoperative Nomogram to Predict Renal Function Insufficiency for Cisplatin-based Adjuvant Chemotherapy Following Minimally Invasive Radical Nephroureterectomy (ROBUUST Collaborative Group).

Eur Urol Focus 2021 Feb 3. Epub 2021 Feb 3.

Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, China. Electronic address:

Background: Postoperative renal function impairment represents a main limitation for delivering adjuvant chemotherapy after radical nephroureterectomy (RNU).

Objective: To create a model predicting renal function decline after minimally invasive RNU.

Design, Setting, And Participants: A total of 490 patients with nonmetastatic UTUC who underwent minimally invasive RNU were identified from a collaborative database including 17 institutions worldwide (February 2006 to March 2020). Renal function insufficiency for cisplatin-based regimen was defined as estimated glomerular filtration rate (eGFR) <50 ml/min/1.73 m at 3 mo after RNU. Patients with baseline eGFR >50 ml/min/1.73 m (n = 361) were geographically divided into a training set (n = 226) and an independent external validation set (n = 135) for further analysis.

Outcome Measurements And Statistical Analysis: Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, a nomogram to predict postoperative eGFR <50 ml/min/1.73 m was built based on the coefficients of the least absolute shrinkage and selection operation (LASSO) logistic regression. The discrimination, calibration, and clinical use of the nomogram were investigated.

Results And Limitations: The model that incorporated age, body mass index, preoperative eGFR, and hydroureteronephrosis was developed with an area under the curve of 0.771, which was confirmed to be 0.773 in the external validation set. The calibration curve demonstrated good agreement. Besides, the model was converted into a risk score with a cutoff value of 0.583, and the difference between the low- and high-risk groups both in overall death risk (hazard ratio [HR]: 4.59, p < 0.001) and cancer-specific death risk (HR: 5.19, p < 0.001) was statistically significant. The limitation mainly lies in its retrospective design.

Conclusions: A nomogram incorporating immediately available clinical variables can accurately predict renal insufficiency for cisplatin-based adjuvant chemotherapy after minimally invasive RNU and may serve as a tool facilitating patient selection.

Patient Summary: We have developed a model for the prediction of renal function loss after radical nephroureterectomy to facilitate patient selection for perioperative chemotherapy.
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http://dx.doi.org/10.1016/j.euf.2021.01.014DOI Listing
February 2021

Development of a Novel Risk Score to Select the Optimal Candidate for Cytoreductive Nephrectomy Among Patients with Metastatic Renal Cell Carcinoma. Results from a Multi-institutional Registry (REMARCC).

Eur Urol Oncol 2021 Apr 29;4(2):256-263. Epub 2020 Dec 29.

Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain. Electronic address:

Background: Selection of patients for upfront cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) has to be improved.

Objective: To evaluate a new scoring system for the prediction of overall mortality (OM) in mRCC patients undergoing CN.

Design, Setting, And Participants: We identified a total of 519 patients with synchronous mRCC undergoing CN between 2005 and 2019 from a multi-institutional registry (Registry for Metastatic RCC [REMARCC]).

Outcome Measurements And Statistical Analysis: Cox proportional hazard regression was used to test the main predictors of OM. Restricted mean survival time was estimated as a measure of the average overall survival time up to 36 mo of follow-up. The concordance index (C-index) was used to determine the model's discrimination. Decision curve analyses were used to compare the net benefit from the REMARCC model with International mRCC Database Consortium (IMDC) or Memorial Sloan Kettering Cancer Center (MSKCC) risk scores.

Results And Limitations: The median follow-up period was 18 mo (interquartile range: 5.9-39.7). Our models showed lower mortality rates in obese patients (p = 0.007). Higher OM rates were recorded in those with bone (p = 0.010), liver (p = 0.002), and lung metastases (p < 0.001). Those with poor performance status (<80%) and those with more than three metastases had also higher OM rates (p = 0.026 and 0.040, respectively). The C-index of the REMARCC model was higher than that of the MSKCC and IMDC models (66.4% vs 60.4% vs 60.3%). After stratification, 113 (22.0%) patients were classified to have a favorable (no risk factors), 202 (39.5%) an intermediate (one or two risk factors), and 197 (38.5%) a poor (more than two risk factors) prognosis. Moreover, 72 (17.2%) and 51 (13.9%) patients classified as having an intermediate and a poor prognosis according to MSKCC and IMDC categories, respectively, would be reclassified as having a good prognosis according to the REMARCC score.

Conclusions: Our findings confirm the relevance of tumor and patient features for the risk stratification of mRCC patients and clinical decision-making regarding CN. Further prospective external validations are required for the scoring system proposed herein.

Patient Summary: Current stratification systems for selecting patients for kidney removal when metastatic disease is shown are controversial. We suggest a system that includes tumor and patient features besides the systems already in use, which are based on blood tests.
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http://dx.doi.org/10.1016/j.euo.2020.12.010DOI Listing
April 2021

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T3a Renal Masses: A Multicenter Analysis.

Eur Urol Focus 2020 Nov 25. Epub 2020 Nov 25.

Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA. Electronic address:

Background: Use of partial nephrectomy (PN) in T3 renal cell carcinoma (RCC) is controversial.

Objective: To evaluate quality outcomes of robot-assisted PN (RAPN) for clinical T3a renal masses (cT3aRM).

Design, Setting, And Participants: This was a retrospective multicenter analysis of patients with cT3aN0M0 RCC who underwent RAPN.

Intervention: RAPN.

Outcome Measurements And Statistical Analysis: The primary endpoint was a trifecta composite outcome of negative surgical margins, warm ischemia time (WIT) ≤25 min, and no perioperative complications. The optimal outcome was defined as achieving this trifecta and ≥90% preservation of the estimated glomerular filtration rate (eGFR) and no stage upgrading of chronic kidney disease. Multivariable analysis (MVA) identified risk factors associated with lack of the optimal outcome. Kaplan-Meier analysis was conducted for survival outcomes.

Results And Limitations: Analysis was conducted for 157 patients (median follow-up 26 mo). The median tumor size was 7.0 cm (interquartile range [IQR] 5.0-7.8) and the median RENAL score was 9 (IQR 8-10). Median estimated blood loss (EBL) was 242 ml (IQR 121-354) and the median WIT was 19 min (IQR 15-25). A total of 150 patients (95.5%) had negative margins. Complications were noted in 25 patients (15.9%), with 4.5% having Clavien grade 3-5 complications. The median change in eGFR was 7 ml/min/1.72 m, with ≥90% eGFR preservation in 55.4%. The trifecta outcome was achieved for 64.3% and the optimal outcome for 37.6% of the patients. MVA revealed that greater age (odds ratio [OR] 1.06; p = 0.002), increasing RENAL score (OR 1.30; p = 0.035), and EBL >300 ml (OR 5.96, p = 0.006) were predictive of failure to achieve optimal outcome. The 5-yr recurrence-free survival, cancer-specific survival, and overall survival, were 82.1%, 93.3%, and 91.3%, respectively. Limitations include the retrospective design.

Conclusions: RAPN for select cT3a renal masses is feasible and safe, with acceptable quality outcomes. Further investigation is requisite to delineate the role of RAPN in cT3a RCC.

Patient Summary: Robot-assisted partial nephrectomy in patients with stage 3a kidney cancer provided acceptable survival, functional, and morbidity outcomes in the hands of experienced surgeons, and may be considered as an option when clinically indicated.
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http://dx.doi.org/10.1016/j.euf.2020.10.011DOI Listing
November 2020

Robot-assisted Radical Nephrectomy: A Systematic Review and Meta-analysis of Comparative Studies.

Eur Urol 2020 Nov 17. Epub 2020 Nov 17.

Division of Urology, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA. Electronic address:

Context: Radical nephrectomy (RN) is the gold standard treatment for large and locally advanced renal tumors. Although robot-assisted radical nephrectomy (RRN) is being increasingly adopted, it remains unclear whether it offers benefits over standard laparoscopic radical nephrectomy (LRN) or open radical nephrectomy (ORN).

Objective: To compare the outcomes of robotic surgery to those of laparoscopic and open surgery in patients undergoing RN for renal cell carcinoma (RCC).

Evidence Acquisition: A systematic search was performed across MEDLINE, EMBASE, and Web of Science for retrospective and prospective studies comparing RRN to LRN or ORN. A meta-analysis evaluated perioperative safety, effectiveness, survival, and cost-effectiveness outcomes. The weighted mean difference (WMD) and odds ratio (OR) were used to compare continuous and dichotomous variables, respectively. Quality was assessed using the Newcastle-Ottawa scale. Sensitivity analyses were performed to assess the robustness of the estimates.

Evidence Synthesis: Twelve studies involving 64 221 patients were identified and included in the analysis. Compared to LRN, RRN was associated with statistically significant longer operative time (WMD 37.44 min; p =  0.03), shorter length of stay (WMD -0.84 days; p =  0.02) and higher total costs (WMD US$4700; p < 0.001). Compared to ORN, RRN was associated with shorter length of stay (WMD -3.06 days; p =  0.002), fewer overall complications (OR 0.56; p <  0.001), lower estimated blood loss (WMD -702 ml; p =  0.01), and higher total hospital costs (WMD US$4520; p =  0.004). There was high heterogeneity across all analyses.

Conclusions: In patients undergoing RN for RCC, RRN seems to offer some key advantages compared to ORN, including shorter hospitalization and fewer complications. Compared to LRN, RRN provides similar surgical outcomes but at higher total costs. These findings should be interpreted within the limitations of this type of analysis, given high heterogeneity between studies and poor robustness for most outcomes. Randomized clinical studies with long-term follow-up are needed to obtain more definitive results.

Patient Summary: In patients with renal cell carcinoma, robot-assisted radical nephrectomy shows perioperative advantages compared to open radical nephrectomy, but not compared to laparoscopic radical nephrectomy.
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http://dx.doi.org/10.1016/j.eururo.2020.10.034DOI Listing
November 2020

Utilization of renal mass biopsy in patients with localized renal cell carcinoma: A population-based study utilizing the National Cancer Database.

Urol Oncol 2021 01 5;39(1):79.e1-79.e8. Epub 2020 Nov 5.

Department of Urology, UC San Diego School of Medicine, La Jolla, CA. Electronic address:

Objective: To evaluate trends and factors predicting use of renal mass biopsy (RMB) for localized Renal Cell Carcinoma in the United States (US) in the context of current guidelines recommendations.

Methods: We queried the National Cancer Database for cT1-cT3N0M0 Renal Cell Carcinoma diagnosed between 2004 and 2015. Temporal trends of RMB were characterized based on tumor size, treatment (partial nephrectomy [PN], radical nephrectomy [RN], ablation, and no treatment), age and Charlson Comorbidity Index with slopes compared using analysis of variance. Multivariable analysis was used to determine factors associated with use of RMB.

Results: Of 338,252 patients analyzed, 11.9% (40,276) underwent RMB. Use of RMB increased throughout the study period from 1,586 (7.6%) in 2004 to 5,629 (16.2%) in 2015 (P < 0.001). Use of RMB increased greatest for ablation (27 to 63%, P < 0.001) and tumors 2-4 cm (9 to 20%, P < 0.001). Multivariable analysis showed year of diagnosis (OR = 1.06; P < 0.001), higher education (OR = 1.09; P < 0.001) and insured status (OR = 1.23; P < 0.001) were associated with increased RMB. Compared to tumors ≤2 cm, tumors 2.1-4 cm (OR = 1.36; P=<0.001), 4.1-7 cm (OR = 1.18; P <0.001) and >7 cm (OR = 1.05; P = 0.03) were associated with higher rates of RMB. Compared to RN, PN was not associated with increased RMB (OR = 1.00; P = 0.92), while ablation (OR = 10.90; P < 0.001) and no surgical treatment (OR = 4.83; P < 0.001) were.

Conclusion: RMB utilization increased overall, with largest increase associated with ablation. Nonetheless, only two-thirds of patients underwent RMB with ablation, suggesting persistent underutilization. Rates of RMB for tumors ≤2 cm and in those undergoing no treatment increased less, suggesting less utilization for surveillance. However, rates for tumors >2-4 cm increased more, suggesting selective utilization of RMB to guide decision-making and risk stratification in small renal masses.
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http://dx.doi.org/10.1016/j.urolonc.2020.10.015DOI Listing
January 2021

Robotic-assisted Partial Nephrectomy for "Very Small" (<2 cm) Renal Mass: Results of a Multicenter Contemporary Cohort.

Eur Urol Focus 2020 Nov 3. Epub 2020 Nov 3.

Division of Urology, VCU Health, Richmond, VA, USA. Electronic address:

Background: Patient with "very small" (<2 cm) renal mass can be offered active surveillance, thermal ablation, or partial nephrectomy. The management strategy will consider patient preferences and prioritize potential harms associated with each of these options. To date, outcomes of robot-assisted partial nephrectomy (RAPN) in patients with "very small" renal masses have not been reported.

Objective: To assess the outcomes of RAPN among patients with "very small" renal masses.

Design, Setting, And Participants: This was a retrospective analysis of a multi-institutional database including RAPN cases performed at eight high-volume US and European centers between 2009 and 2019. Patients were stratified into two groups according to clinical tumor size: <2 cm ("very small" renal mass, study group) and 2-4 cm (control group).

Intervention: RAPN for renal masses.

Outcome Measurements And Statistical Analysis: Baseline characteristics and intraoperative, pathological, and postoperative data were compared between the study and the control group. A "trifecta" was used as surrogate of "surgical quality."

Results And Limitations: Overall, a total of 1019 patients were included in the analysis. Of these, 352 had a renal mass of <2 cm (34.5%) and 667 (65.5%) had a renal mass of 2-4 cm. At baseline, the study group presented a lower rate of chronic kidney disease ≥stage III (p < 0.001), a lower RENAL score (p = 0.001), and lower rates of hilar (p = 0.04) and endophytic (p = 0.02) masses. Warm ischemia time was shorter for the study group (median 14 vs 18 min, p < 0.001), which also showed a lower rate of overall postoperative complications (9.6% vs 14.7%, p < 0.001) and no major complications. In terms of oncological outcomes, three and ten patients developed a local recurrence in the study and the control group, respectively (p = 0.1). In the study group, higher estimated glomerular filtration rates were found at discharge (p = 0.001) and at the last follow-up (p = 0.007), which showed a "trifecta" achievement of 90.6%. The retrospective design may limit the generalizability of the findings.

Conclusions: Whenever an active treatment is indicated or warranted, RAPN represents a minimally invasive management option for "very small" renal masses, as it carries minimal risk of complications and has minimal impact on renal function. While both active surveillance and kidney ablation remain valid management options in these cases, RAPN can be offered and discussed with patients as it provides excellent outcomes with low morbidity.

Patient Summary: In this report, we observed that robot-assisted partial nephrectomy represents a true minimally invasive active treatment for "very small" renal masses (<2 cm), as it carries minimal risk of complications and has minimal impact on renal function.
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http://dx.doi.org/10.1016/j.euf.2020.10.001DOI Listing
November 2020

Outcomes of minimally invasive partial nephrectomy among very elderly patients: report from the RESURGE collaborative international database.

Cent European J Urol 2020 8;73(3):273-279. Epub 2020 Sep 8.

Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Milan, Italy.

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass. The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used. Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m. PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01). In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available.
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http://dx.doi.org/10.5173/ceju.2020.0179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587491PMC
September 2020

Pathologic nodal downstaging in men with clinically involved lymph nodes undergoing radical prostatectomy: Implications for definitive locoregional therapy.

Urol Oncol 2021 02 26;39(2):130.e1-130.e7. Epub 2020 Oct 26.

Department of Urology, University of California, San Diego, CA.

A prostate cancer (CaP) patient with nonmetastatic but clinical positive lymph nodes (cN+) represents a difficult clinical scenario. We compare overall survival (OS) between cN+ men that underwent radical prostatectomy (RP) and were found to have negative node status (pN) with those found to have positive nodal status (pN+), and assess predictors of discordant nodal status. We queried the National Cancer Data Base between 2004 and 2015 for patients that were cT1-3 cN+ cM0 CaP treated with RP. Patients with 0 nodes, cT4, or cM1 disease were excluded. We compared groups based on pathologic nodal status: Discordant (cN+ -> pN) & Concordant (cN+ -> pN+). Kaplan Meier estimations were used to compare OS. Logistic regression was used to determine possible predictors of nodal status. We find that of 6470 cN+ patients, 1,367 (21.1%) underwent RP, 866 (13.4%) had confirmed nodal status. Discordant status was found in 159 (18.4%) and concordant staging in 707 (81.6%). Differences exist in PSA at diagnosis (7.3 vs. 11.2), biopsy group, # of nodes examined (7 vs. 10), race, and Charlson index. Discordant staging had longer OS compared to Concordant staging (P = 0.007) and similar OS to a 3:1 matched cohort of high risk localized CaP patients used as reference (P = 0.46). Lower Gleason Score (GG1-3) was associated with an increased likelihood of discordant staging. Clinical nodal staging is associated with a substantial false positive rate. Discordant status had better OS than Concordant status and similar OS to matched patients with localized CaP. Clinical nodal staging may inappropriately lead to noncurative therapy in a substantial number of men with potentially curable disease.
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http://dx.doi.org/10.1016/j.urolonc.2020.08.035DOI Listing
February 2021

Association of Surgical Delay and Overall Survival in Patients With T2 Renal Masses: Implications for Critical Clinical Decision-making During the COVID-19 Pandemic.

Urology 2021 01 20;147:50-56. Epub 2020 Sep 20.

Department of Urology, Wayne State University, Detroit, MI.

Objective: To test for an association between surgical delay and overall survival (OS) for patients with T2 renal masses. Many health care systems are balancing resources to manage the current COVID-19 pandemic, which may result in surgical delay for patients with large renal masses.

Methods: Using Cox proportional hazard models, we analyzed data from the National Cancer Database for patients undergoing extirpative surgery for clinical T2N0M0 renal masses between 2004 and 2015. Study outcomes were to assess for an association between surgical delay with OS and pathologic stage.

Results: We identified 11,848 patients who underwent extirpative surgery for clinical T2 renal masses. Compared with patients undergoing surgery within 2 months of diagnosis, we found worse OS for patients with a surgical delay of 3-4 months (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.00-1.25) or 5-6 months (HR 1.51, 95% CI 1.19-1.91). Considering only healthy patients with Charlson Comorbidity Index = 0, worse OS was associated with surgical delay of 5-6 months (HR 1.68, 95% CI 1.21-2.34, P= .002) but not 3-4 months (HR 1.08, 95% CI 0.93-1.26, P = 309). Pathologic stage (pT or pN) was not associated with surgical delay.

Conclusion: Prolonged surgical delay (5-6 months) for patients with T2 renal tumors appears to have a negative impact on OS while shorter surgical delay (3-4 months) was not associated with worse OS in healthy patients. The data presented in this study may help patients and providers to weigh the risk of surgical delay versus the risk of iatrogenic SARS-CoV-2 exposure during resurgent waves of the COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.urology.2020.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502240PMC
January 2021

Fear of Cancer Recurrence in Patients With Localized Renal Cell Carcinoma.

JCO Oncol Pract 2020 11 18;16(11):e1264-e1271. Epub 2020 Sep 18.

Department of Urology, Ludwig-Maximilians University, Munich, Germany.

Purpose: Patients with cancer commonly report distress and fear of cancer recurrence (FCR) impacting quality of life and clinical outcomes. This study aims to test the association between emotional well-being and clinical characteristics of survivors with localized renal cell carcinoma (RCC).

Materials And Methods: Survivors with localized RCC were invited to participate in this study through social media by the Kidney Cancer Research Alliance. Participants self-reported clinical characteristics, distress (Distress Thermometer), and FCR (Fear of Cancer Recurrence-7). Ordinal regression was used to test the association between emotional well-being and patient characteristics.

Results: A total of 412 survivors were included in this analysis. Participants were mostly female (79.4%) and well educated (58.3%), with a median age of 54 years (range, 30-80 years) and median time since diagnosis of 17.5 months. More than one half were diagnosed with stage I disease (56.1%). Most patients (62.3%) had a clear understanding of their diagnosis. A high prevalence of moderate to severe distress (67.0%) and FCR (54.9%) was reported across all survivors of RCC. Higher FCR was associated with female gender, younger age, and lack of understanding of their diagnosis ( = .001), whereas more recent diagnosis was associated with higher distress levels ( = .01).

Conclusion: Our findings suggest that FCR is a common problem that is persistent after therapy and that certain individuals, including female and younger patients, may be at particular risk of experiencing clinically relevant FCR.
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http://dx.doi.org/10.1200/OP.20.00105DOI Listing
November 2020

NCCN Guidelines Insights: Kidney Cancer, Version 1.2021.

J Natl Compr Canc Netw 2020 09;18(9):1160-1170

National Comprehensive Cancer Network.

The NCCN Guidelines for Kidney Cancer provide multidisciplinary recommendations for diagnostic workup, staging, and treatment of patients with renal cell carcinoma (RCC). These NCCN Guidelines Insights focus on recent updates to the guidelines, including changes to certain systemic therapy recommendations for patients with relapsed or stage IV RCC. They also discuss the addition of a new section to the guidelines that identifies and describes the most common hereditary RCC syndromes and provides recommendations for genetic testing, surveillance, and/or treatment options for patients who are suspected or confirmed to have one of these syndromes.
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http://dx.doi.org/10.6004/jnccn.2020.0043DOI Listing
September 2020

Outcomes of robot-assisted partial nephrectomy for completely endophytic renal tumors: A multicenter analysis.

Eur J Surg Oncol 2020 Aug 16. Epub 2020 Aug 16.

Division of Urology, VCU Health, Richmond, VA, USA. Electronic address:

Introduction: Multicenter retrospective analysis of robotic partial nephrectomy for completely endophytic renal tumors (i.e. 3 points for the 'E' domain of the R.E.N.A.L. nephrometry score) was performed.

Materials And Methods: Patients' demographics, tumor characteristics, perioperative, functional, pathological and oncological data were analyzed and compared with those of patients with exophytic and mesophytic masses (i.e. 1 and 2 points for the 'E' domain, respectively). Multivariable logistic regression analysis was used to assess variables for trifecta achievement (negative margin, no postoperative complications, and 90% estimated glomerular filtration rate [eGFR] recovery).

Results: Overall, 147 patients were included in the study group. Patients with a completely endophytic mass had bigger tumors (mean 4.2 vs. 4.1 vs. 3.2 cm; p < 0.001) on preoperative imaging and higher overall R.E.N.A.L. score. There was no difference in mean operative time. Estimated blood loss was higher in the endophytic group (mean 177.75 vs. 185.5 vs. 130 ml; p = 0.001). Warm ischemia time was shorter for the exophytic group (median 16 vs. 21 vs. 22 min; p < 0.001). Postoperative complications were more frequent in patients with endophytic tumor (24.8% vs. 19.5% vs. 14.8%; p < 0.001). Six (4.5%) patients had positive surgical margins, there was no difference between groups. Trifecta was achieved in 44 patients in endophytic group (45.4 vs. 68.8 and 50.9%, p < 0.001). Multivariable analysis for trifecta revealed that clinical tumor size (odds ratio: 0.667, 95% confidence interval: 0.56-0.79, p < 0.001) was only significant predictor for trifecta achievement.

Conclusions: Our findings confirm that RAPN in case of completely endophytic renal masses can be performed with acceptable outcomes in centers with significant robotic expertise.
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http://dx.doi.org/10.1016/j.ejso.2020.08.012DOI Listing
August 2020

Elevated preoperative C-reactive protein is associated with renal functional decline and non-cancer mortality in surgically treated renal cell carcinoma: analysis from the INternational Marker Consortium for Renal Cancer (INMARC).

BJU Int 2021 Mar 19;127(3):311-317. Epub 2020 Nov 19.

Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA.

Objective: To investigate association of preoperative C-reactive protein (CRP) and non-cancer mortality (NCM) in a cohort of patients undergoing surgery for localised renal cell carcinoma (RCC).

Patients And Methods: Retrospective multicentre analysis of patients surgically treated for clinical Stage 1-2 RCC from 2006 to 2017, excluding all cases of cancer-specific mortality. Descriptive analyses were obtained between the pre-treatment normal-CRP (≤5 mg/L) and elevated-CRP (>5 mg/L) groups. The primary outcome was NCM. The secondary outcomes included progression to de novo chronic kidney disease Stages 3-4 (estimated glomerular filtration rate [eGFR] of <60, <45, and <30 mL/min/1.73 m ). Multivariable analyses (MVA) were performed to assess for risk factors associated with functional decline and NCM, and Kaplan-Meier analysis was used to obtain survival estimates for outcomes.

Results: A total of 1987 patients who underwent radical or partial nephrectomy were analysed (normal-CRP group, n = 963; elevated-CRP group, n = 1024). Groups were similar in age (59 vs 60 years, P = 0.079). An elevated CRP was more frequent in males (36.8% vs 27.8%, P < 0.001), African-Americans (22.6% vs 2.9%, P < 0.001), and in those with a higher median body mass index (30 vs 25 kg/m , P < 0.001) and larger median tumour size (4.5 vs 3.3 cm, P < 0.001). On MVA, an elevated CRP was independently associated with development of de novo eGFR of <60 mL/min/1.73 m (hazard ratio [HR] 1.32, P = 0.015), <45 mL/min/1.73 m (HR 1.41, P = 0.023) and <30 mL/min/1.73 m (odds ratio 2.23, P < 0.001). The MVA for factors associated with NCM demonstrated increasing age (HR 1.06, P < 0.001), preoperative elevated CRP (HR 2.18, P < 0.001) and an eGFR of <45 mL/min/1.73 m (HR 1.16; P = 0.021) as independent risk factors. Kaplan-Meier analysis revealed significantly higher 5-year NCM in the elevated-CRP group vs the normal-CRP group (98% vs 80%, P < 0.001).

Conclusions: Pre-treatment elevated CRP was independently associated with both progressive renal functional decline and NCM in patients undergoing surgery for Stage 1-2 RCC. Patients with elevated CRP and Stage 1 and 2 RCC may be considered as having indication for nephron-sparing strategies, which may be prioritised if oncologically appropriate.
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http://dx.doi.org/10.1111/bju.15200DOI Listing
March 2021

Impact of positive surgical margins on survival after partial nephrectomy in localized kidney cancer: analysis of the National Cancer Database.

Minerva Urol Nefrol 2020 Aug 4. Epub 2020 Aug 4.

Department of Urology, University of California San Diego School of Medicine, La Jolla, California, USA -

Background: The impact of positive surgical margins (PSM) on outcomes in partial nephrectomy (PN) is controversial. We investigated impact of PSM for patients undergoing PN on overall survival (OS) in different stages of renal cell carcinoma (RCC).

Methods: Retrospective analysis of patients from the US National Cancer Database who underwent PN for cT1a-cT2b N0M0 RCC between 2004-13. Patients were stratified by pathological stage [pT1a, pT1b, pT2a, pT2b, and pT3a (upstaged)] and analyzed by margin status. Cox Regression multivariable analysis (MVA) was performed to investigate associations of PSM and covariates on all-cause mortality (ACM). Kaplan-Meier analysis (KMA) of OS was performed for PSM versus negative margin (NSM) by pathological stage. Subanalysis of Charlson Comorbidity Index 0 (CCI=0) subgroup was conducted to reduce bias from comorbidities.

Results: We analyzed 42,113 PN [pT1a 33341 (79.2%) pT1a, pT1b 6689 (15.9%), pT2a 757 (1.8%), pT2b 165 (0.4%) and pT3a upstaged 1161 (2.8%)]. PSM occurred in 6.7% (2823) [pT1a 6.5%, pT1b 6.3%, pT2a 5.9%, pT2b 6.1%, pT3a 14.1% p<0.001]. On MVA, PSM was associated with 31% increase in ACM (HR 1.31, p<0.001), which persisted in CCI=0 subanalysis (HR 1.25, p<0.001). KMA revealed negative impact of PSM vs. NSM on 5-year OS: pT1 (87.3% vs. 90.9%, p<0.001), pT2 (86.7% vs. 82.5%, p=0.48), and upstaged pT3a (69% vs. 84.2%, p<0.001).

Conclusions: PSM after PN was independently associated with across-the-board decrement in OS, which worsened in pT3a disease and persisted in subanalysis of patients with CCI=0. PSM should prompt more aggressive surveillance or definitive resection strategies.
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http://dx.doi.org/10.23736/S0393-2249.20.03728-5DOI Listing
August 2020

Oncologic and Functional Outcomes of Radical and Partial Nephrectomy in pT3a Pathologically Upstaged Renal Cell Carcinoma: A Multi-institutional Analysis.

Clin Genitourin Cancer 2020 Dec 11;18(6):e723-e729. Epub 2020 May 11.

University of California San Diego, La Jolla, CA. Electronic address:

Background: The efficacy of partial nephrectomy (PN) in setting of pT3a pathologic-upstaged renal cell carcinoma (RCC) is controversial. We compared oncologic and functional outcomes of radical nephrectomy (RN) and PN in patients with upstaged pT3a RCC.

Patients And Methods: This was a multicenter retrospective analysis of patients with cT1-2N0M0 RCC upstaged to pT3a postoperatively. The primary outcome was recurrence-free survival, with secondary outcomes of overall survival and de novo estimated glomular filtration rate (eGFR) < 60. Multivariable analysis was performed to identify predictive factors for oncologic outcomes. Kaplan-Meier analyses (KMA) were obtained to elucidate survival outcomes.

Results: A total of 929 patients had pT3a upstaging (686 [72.6%] RN; 243 [25.7%] PN; mean follow-up, 48 months). Tumor size was similar (RN 7.7 cm vs. PN 7.3 cm; P = .083). PN had decreased ΔeGFR (6.1 vs. RN 19.4 mL/min/1.73m; P < .001) and de novo eGFR < 60 (9.5% vs. 21%; P = .008). Multivariable analysis for recurrence showed increasing RENAL score (hazard ratio [HR], 3.8; P < .001), clinical T stage (HR, 1.8; P < .001), positive margin (HR, 1.57; P = .009), and high grade (HR, 1.21; P = .01) to be independent predictors, whereas surgery was not (P = .076). KMA revealed 5-year recurrence-free survival for cT1-upstaged PN, cT1-upstaged RN, cT2-upstaged PN, and cT2-upstaged RN of 79%, 74%, 70%, and 51%, respectively (P < .001). KMA revealed 5-year overall survival for cT1-upstaged PN, cT1-upstaged RN, cT2-upstaged PN, and cT2-upstaged RN of 64%, 65.2%, 56.4%, and 55.2%, respectively (P = .059).

Conclusions: In pathologically upstaged pT3a RCC, PN did not adversely affect risk of recurrence and provided functional benefit. Surgical decision-making in patients at risk for T3a upstaging should be individualized and driven by tumor as well as functional risks.
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http://dx.doi.org/10.1016/j.clgc.2020.05.002DOI Listing
December 2020

Upstaging to pT3a in Patients Undergoing Partial or Radical Nephrectomy for cT1 Renal Tumors: A Systematic Review and Meta-analysis of Outcomes and Predictive Factors.

Eur Urol Focus 2020 Jun 19. Epub 2020 Jun 19.

Division of Urology, VCU Health System, Richmond, VA, USA. Electronic address:

Context: Predictors of upstaging from cT1 to pT3a renal masses are poorly inquired, and this remains an area of controversial findings.

Objective: To evaluate predictors and outcomes of upstaging from cT1 to pT3a in patients undergoing surgical removal of a renal tumor.

Evidence Acquisition: A systematic literature search was performed to identify relevant articles using three electronic engines (PubMed, Embase, and Web of Science). Only studies looking at upstaging to pT3a in patients undergoing either partial nephrectomy (PN) or radical nephrectomy (RN) for cT1 renal tumor were included. Study selection was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.

Evidence Synthesis: Thirteen studies, including 21869 patients (cT1/pT3a: 1256 [5.7%]; cT1/pT1: 20613 [93.3%]), were identified. Patients in the upstaged group were older (weighted mean difference [WMD]: 3.89; p < 0.00001) and mostly male (odds ratio [OR]: 1.23; p = 0.04). Renal tumors were larger (WMD: 0.98; p < 0.00001), more complex (OR: 2.38; p < 0.0001), and with a higher rate of cT1b masses (OR: 3.36; p < 0.00001). The cT1/pT3a group had a higher rate of other renal cell carcinoma histological subtypes (OR: 1.59; p = 0.04), as well as higher odds of Fuhrman grade ≥3 (OR: 2.57; p < 0.00001) and positive surgical margins (OR: 1.85; p = 0.007). Five-year recurrence-free survival (RFS) was worse in the upstaged group (OR: 0.31; p = 0.02). Age (OR: 1.03; p < 0.00001), tumor size (OR: 1.51; p < 0.00001), and RENAL score (OR: 2.80; p = 0.0004) were predictors of upstaging. Upstaging was associated with overall survival (hazard ratio [HR]: 1.94; p = 0.05), cancer-specific survival (HR: 2.24; p = 0.007), and RFS (HR: 2.17; p < 0.00001).

Conclusions: Upstaging to pT3a in case of surgical removal of a cT1 renal tumor is an uncommon event, which however can translate into worse oncological outcomes. Both patient (older age) and tumor (larger size and higher complexity) characteristics are associated with a higher risk of upstaging. There is very limited evidence regarding whether RN would be better than PN in these cases. There remains an unmet need for tools to better characterize renal masses in the preoperative setting.

Patients Summary: About 6% of surgically treated localized renal tumors can be found to be locally advanced on final pathology after surgery. This "upstaging" can translate into worse oncological outcomes. There are patient and tumor characteristics that are associated with an increased the risk of upstaging.
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http://dx.doi.org/10.1016/j.euf.2020.05.013DOI Listing
June 2020

Comparison of renal functional outcomes of active surveillance and partial nephrectomy in the management of oncocytoma.

World J Urol 2020 Jun 17. Epub 2020 Jun 17.

Department of Urology, UC San Diego School of Medicine, 3855 Health Sciences Drive, 0987, La Jolla, CA, 92093-0987, USA.

Purpose: To compare functional outcomes of partial nephrectomy (PN) and active surveillance (AS) in oncocytoma.

Methods: Multicenter retrospective analysis of patients with oncocytoma managed with PN or AS (biopsy-confirmed). Primary outcome development of de novo chronic kidney disease (CKD) (eGFR < 60 mL/min/1.73m). Cox regression Multivariable analysis (MVA) was carried out for predictors of de novo CKD. Linear regression was carried out for factors associated with increasing deltaGFR. Kaplan-Meier Analysis (KMA) was performed to analyze 5-year CKD-free survival.

Results: 295 patients were analyzed (224 PN/71 AS, median follow-up 37.4 months). No differences were noted for clinical tumor size (AS 2.6 vs. PN 2.9 cm, p = 0.108), and baseline eGFR (AS 79.6 vs. PN 77, p = 0.9670). Median change in tumor diameter for AS was 0.42 cm. Compared to PN, AS had deltaGFR (-15.3 vs. -6.4 mL/min/1.73m, p < 0.001) and de novo CKD (28.2% vs. 12.1%, p = 0.002). AS patients who developed CKD had higher RENAL score (p = 0.005) and lower baseline eGFR (73 vs. 91.2 mL/min/1.73m, p < 0.001) than AS patients who did not. MVA demonstrated increasing age (OR = 1.03, p = 0.025), tumor size (HR = 1.26, p = 0.032) and AS (HR = 4.91, p < 0.001) to be predictive for de novo CKD. Linear regression demonstrated AS was associated with larger decrease in deltaGFR (B = -0.219, p < 0.001). KMA revealed 5-year CKD survival was higher in PN (87%) vs. AS (62%, p < 0.001).

Conclusion: AS was associated with greater functional decline than PN in oncocytoma. PN may be considered to optimalize renal functional preservation in select circumstances. Further investigation into mechanisms of functional decline in oncocytoma is requisite.
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http://dx.doi.org/10.1007/s00345-020-03299-5DOI Listing
June 2020

Rates and Predictors of Perioperative Complications in Cytoreductive Nephrectomy: Analysis of the Registry for Metastatic Renal Cell Carcinoma.

Eur Urol Oncol 2020 08 12;3(4):523-529. Epub 2020 May 12.

Department of Urology, University Hospitals Leuven, Leuven, Belgium.

Background: Cytoreductive nephrectomy (CN) plays an important role in the treatment of a subgroup of metastatic renal cell carcinoma (mRCC) patients.

Objective: We aimed to evaluate morbidity associated with this procedure and identify potential predictors thereof to aid patient selection for this procedure and potentially improve patient outcomes.

Design, Setting, And Participants: Data from 736 mRCC patients undergoing CN at 14 institutions were retrospectively recorded in the Registry for Metastatic RCC (REMARCC).

Outcome Measurements And Statistical Analysis: Logistic regression analysis was used to identify predictors for intraoperative, any-grade (AGCs), low-grade, and high-grade (HGCs) postoperative complications (according to the Clavien-Dindo classification) as well as 30-d readmission rates.

Results And Limitations: Intraoperative complications were observed in 69 patients (10.9%). Thrombectomy (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.08-1.75, p = 0.009) and adjacent organ removal (OR 2.7, 95% CI 1.38-5.30) were significant predictors of intraoperative complications at multivariable analysis. Two hundred seventeen patients (29.5%) encountered AGCs, while 45 (6.1%) encountered an HGC, of whom 10 (1.4%) died. Twenty-four (3.3%) patients had multiple postoperative complications. Estimated blood loss (EBL; OR 1.49, 95% CI 1.08-2.05, p = 0.01) was a significant predictor of AGCs at multivariable analysis. CN case load (OR 0.13, 95% CI 0.03-0.59, p = 0.009) and EBL (OR 2.93, 95% CI 1.20-7.15, p = 0.02) were significant predictors solely for HGCs at multivariable analysis. Forty-one patients (11.5%) were readmitted within 30 d of surgery. No significant predictors were identified. Results were confirmed in a subanalysis focusing solely on patients treated in the contemporary targeted therapy era.

Conclusions: Morbidity associated with CN is not negligible. Predictors of high-grade postoperative morbidity are predominantly indicators of complex surgery. EBL is a strong predictor of postoperative complications. CN case load correlates with lower high-grade morbidity and highlights the benefit of centralization of complex surgery. However, risks and benefits should be balanced when considering CN in mRCC patients.

Patient Summary: We studied patients with metastatic renal cancer to evaluate the outcomes associated with the surgical removal of the primary kidney tumor. We found that this procedure is often complex and adverse events are not uncommon. High intraoperative blood loss and a small number of cases performed at the treating center are associated with a higher rate of postoperative complications.
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http://dx.doi.org/10.1016/j.euo.2020.04.006DOI Listing
August 2020

Outcomes and predictors of benign histology in patients undergoing robotic partial or radical nephrectomy for renal masses: a multicenter study.

Cent European J Urol 2020 23;73(1):33-38. Epub 2020 Mar 23.

Division of Urology, Virginia Commonwealth University Health System, Richmond, VA, USA.

Introduction: Theaim of this study was to assess preoperative factors associated with benign histology in patients undergoing surgical removal of a renal mass and to analyze outcomes of robotic partial nephrectomy (PN) and radical nephrectomy (RN) for these masses.

Material And Methods: Overall, 2,944 cases (543 benign and 2,401 malignant) who underwent robotic PN and RN between 2003-2018 at 10 institutions worldwide were included. The assessment of the predictors of benign histology was made at the final surgical pathology report. Descriptive statistics, Mann-Whitney U, Pearson's χ, and logistic regression analysis were used.

Results: Patients in the benign group were mostly female (61 vs. 33%; p <0.001), with lower body mass index (BMI) (26.0 vs. 27.1 kg/m; p <0.001). The benign group presented smaller tumor size (2.8 vs. 3.5 cm; p <0.001), R.E.N.A.L. score (6.0 vs. 7.0; p <0.001). There was a lower rate of hilar (11 vs.18%; p = 0.001), cT≥3 (1 vs. 4.5%; p <0.001) tumors in the benign group. There was a statistically significant higher rate of PN in the benign group (97 vs. 86%; p <0.001) as well as a statistically significant lower 30-day re-admission rate (2 vs. 5%; p = 0.081). Multivariable analysis showed male gender (OR: 0.52; p <0.001), BMI (OR: 0.95; p <0.001), and cT3a (OR: 0.22; p = 0.005) to be inversely associated to benign histology.

Conclusions: In 18% of cases, a benign histologic type was found. Only 3% of these tumors were treated with RN. Female gender, lower BMI, and higher T staging showed to be independent predictors of benign histology.
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http://dx.doi.org/10.5173/ceju.2020.0019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7203778PMC
March 2020

The Impact of Age and Gender on Outcomes of Patients With Advanced Renal Cell Carcinoma Treated With Targeted Therapy.

Clin Genitourin Cancer 2020 10 16;18(5):e598-e609. Epub 2020 Mar 16.

Department of Medicine, Division of Hematology/Oncology, University of California San Diego, Moores Cancer Center, La Jolla, CA. Electronic address:

Background: A growing body of evidence suggests that age and gender play a role in cancer outcomes. The objective of this study was to investigate the effect of age and gender on survival of patients with metastatic renal cell carcinoma (RCC).

Methods: We conducted a pooled analysis of patients with metastatic RCC treated on phase II and III clinical trials. Patients were stratified by age (young [<50 years], intermediate [50-70 years], versus elderly [>70 years]) and gender. Statistical analyses were performed using Cox regression adjusted for several risk factors and the Kaplan-Meier method.

Results: We identified 4736 patients with metastatic RCC. Overall, there was no difference in overall survival (OS) when stratified by age (21.0 vs. 17.3 months for elderly vs. intermediate age groups, P = .382; 20.0 vs. 17.3 months for young vs. intermediate age groups, P = .155) or gender (19.8 vs. 19.0 for male vs. female, P = .510). Progression-free survival (PFS) was shorter in younger individuals compared with the intermediate age patients (6.0 vs. 7.1 months, P < .001), but similar across gender groups. Although all grade adverse events were more common in elderly patients (fatigue, diarrhea, decreased appetite, and weight), serious adverse events were similar between groups.

Conclusions: Although OS was similar between age groups, younger individuals had a shorter PFS. Gender was not an independent determinant of survival. Elderly patients experienced more adverse events than their younger counterparts. These findings are important to guide clinicians when counseling patients about expectations and toxicity associated with therapy.
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http://dx.doi.org/10.1016/j.clgc.2020.03.010DOI Listing
October 2020

Robotic partial nephrectomy vs minimally invasive radical nephrectomy for clinical T2a renal mass: a propensity score-matched comparison from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group.

BJU Int 2020 07 15;126(1):114-123. Epub 2020 Jun 15.

Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA.

Objective: To compare outcomes of minimally invasive radical nephrectomy (MIS-RN) and robot-assisted partial nephrectomy (RAPN) in clinical T2a renal mass (cT2aRM).

Patients And Methods: Retrospective, multicentre, propensity score-matched (PSM) comparison of RAPN and MIS-RN for cT2aRM (T2aN0M0). Cohorts were PSM for age, sex, body mass index, American Society of Anesthesiologists (ASA) class, clinical tumour size, and R.E.N.A.L. score using a 2:1 ratio for RN:PN. The primary outcome was disease-free survival (DFS). Secondary outcomes included overall survival (OS), complication rates, and de novo estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m . Multivariable (MVA) and Kaplan-Meier survival analyses (KMSA) were conducted.

Results: In all, 648 patients (216 RAPN/432 MIS-RN) were matched. There were no significant differences in intraoperative complications (P = 0.478), Clavien-Dindo Grade ≥III complications (P = 0.063), and re-admissions (P = 0.238). The MVA revealed high ASA class (hazard ratio [HR] 2.7, P = 0.044) and sarcomatoid (HR 5.3, P = 0.001), but not surgery type (P = 0.601) to be associated with all-cause mortality. Increasing R.E.N.A.L. score (HR 1.31, P = 0.037), high tumour grade (HR 2.5, P = 0.043), and sarcomatoid (HR 2.8, P = 0.02) were associated with recurrence, but not surgery (P = 0.555). Increasing age (HR 1.1, P < 0.001) and RN (HR 3.9, P < 0.001) were predictors of de novo eGFR of <45 mL/min/1.73 m . Comparing RAPN and MIS-RN, KMSA revealed no significant differences for 5-year OS (76.3% vs 88.0%, P = 0.221) and 5-year DFS (78.6% vs 85.3%, P = 0.630) for pT2 RCC, and no differences for 3-year OS (P = 0.351) and 3-year DFS (P = 0.117) for pT3a upstaged RCC. The 5-year freedom from de novo eGFR of <45 mL/min/1.73 m was 91.6% for RAPN vs 68.9% for MIS-RN (P < 0.001).

Conclusions: RAPN had similar oncological outcomes and morbidity profile as MIS-RN, while conferring functional benefit. RAPN may be considered as a first-line option for cT2aRM.
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http://dx.doi.org/10.1111/bju.15064DOI Listing
July 2020

Female Gender Predicts Favorable Prognosis in Patients With Non-metastatic Clear Cell Renal Cell Carcinoma Undergoing Curative Surgery: Results From the International Marker Consortium for Renal Cancer (INMARC).

Clin Genitourin Cancer 2020 04 6;18(2):111-116.e1. Epub 2019 Nov 6.

Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan.

Background: There is no clear consensus regarding gender differences in the prognosis of patients with clear-cell renal cell carcinoma (ccRCC). In the present study, we investigated the prognostic value of gender in patients with non-metastatic ccRCC undergoing curative surgery using the inverse probability of treatment weighting (IPTW) method to balance the difference in baseline factors between females and males.

Patients And Methods: We retrospectively reviewed the International Marker Consortium for Renal Cancer (INMARC) dataset and included 2055 patients with cT1-4N0M0 ccRCC who underwent partial or radical nephrectomy. The IPTW method was used to adjust for baseline characteristics between females and males (age, race, surgery type, and pT stage), and the association of gender with recurrence-free survival (RFS) was evaluated.

Results: During the follow-up (median, 30 months), 162 (8%) patients had disease recurrence (5-year RFS rate, 88%). Female gender (n = 712; 35%) was significantly associated with a lower Fuhrman grade (unweighted, P = .022; IPTW-weighted, P < .001). Females had significantly better RFS compared with males (unweighted, 5-year RFS rate, 92% vs. 87%; P = .005; IPTW-weighted, 5-year RFS rate, 92% vs. 86%; P = .002). IPTW-weighted multivariate analysis showed that female gender was an independent predictor for better RFS (hazard ratio, 0.59; P = .005) along with lower pT stage and lower Fuhrman grade. The prognostic significance of female gender was also observed in the unweighted multivariate analysis.

Conclusion: Female gender was significantly associated with a lower Fuhrman grade and better prognosis for patients with non-metastatic ccRCC undergoing curative surgery.
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http://dx.doi.org/10.1016/j.clgc.2019.10.027DOI Listing
April 2020

Upstaging to pT3a disease in patients undergoing robotic partial nephrectomy for cT1 kidney cancer: Outcomes and predictors from a multi-institutional dataset.

Urol Oncol 2020 04 16;38(4):286-292. Epub 2020 Jan 16.

Division of Urology, Department of Surgery, VCU Health System, Richmond, VA. Electronic address:

Objectives: Surgically treated clinical T1 (cT1) kidney cancer has in general a good prognosis, but there is a risk of upstaging that can potentially jeopardize the oncological outcomes after partial nephrectomy (PN). Aim of this study is to analyze the outcomes of robot-assisted PN (RAPN) for cT1 kidney cancer upstaged to pT3a, and to identify predictors of upstaging.

Material And Methods: The study cohort included 1,640 cT1 patients who underwent RAPN between 2005 and 2018 at 10 academic institutions. Multivariate logistic regression model was used to assess the predictors of upstaging. Kaplan-Meier curves and multivariable Cox regression analyses were used to evaluate recurrence-free survival and overall survival.

Results: Overall, 74 (4%) were upstaged cases (cT1/pT3a). Upstaged patients presented larger renal tumors (3.1 vs. 2.4 cm; P = 0.001), and higher R.E.N.A.L. score (8.0 vs. 6.0; P = 0.004). cT1/pT3a group had higher rate of intraoperative complications (5 vs. 1% P = 0.032), higher pathological tumor size (3.2 vs. 2.5 cm; P < 0.001), higher rate of Fuhrman grade ≥3 (32 vs. 17%; P = 0.002), and higher number of sarcomatoid differentiation (4 vs. 1%; P = 0.008). Chronic kidney disease (CKD) stage ≥3 (OR: 2.54; P < 0.014), and clinical tumor size (OR: 1.07; P < 0.001) were independent predictors of upstaging. cT1/pT3a group had worse 2-year (94% vs. 99%) recurrence-free survival (P < 0.001).

Conclusions: Upstaging to pT3a in patients with cT1 renal mass undergoing RAPN represents an uncommon event, involving less than 5% of cases. Pathologic upstaging might translate into worse oncological outcomes, and therefore strict follow-up protocols should be applied in these cases.
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http://dx.doi.org/10.1016/j.urolonc.2019.12.024DOI Listing
April 2020

Effect of Obesity and Overweight Status on Complications and Survival After Minimally Invasive Kidney Surgery in Patients with Clinical T Renal Masses.

J Endourol 2020 03;34(3):289-297

Department of Medical, Oral and Biotechnological Sciences, Urology Unit, SS Annunziata Hospital, "G.D'Annunzio" University of Chieti, Chieti, Italy.

To evaluate the effect of obesity and overweight on surgical, functional, and survival outcomes in patients with large kidney masses after minimally invasive surgery. Within a multicenter multinational dataset, patients found to have ≥cT renal mass and treated with minimally invasive (laparoscopic or robotic) kidney surgery (radical or partial nephrectomy) during the period 2003 to 2017 were abstracted. They were stratified according to the body mass index classes as normal weight (18.5-24.9 kg/m), overweight (25.0-29.9 kg/m), and obese (≥30.0 kg/m). Mixed models and Cox proportional hazard regression tested differences in complication rates, estimated glomerular filtration rate (eGFR) change over time, overall mortality (OM), and disease recurrence (DR) rates. Of 812 patients, 30.6% were normal weight, 42.7% were overweight, and 26.7% obese. Overweight (odds ratio 0.82, 95% confidence interval [CI]: 0.51-1.31,  = 0.406) and obese patients (OR: 0.81, 95% CI: 0.44-1.47,  = 0.490) experienced similar complication rates than normal weight. Moreover, no statistically significant differences in eGFR were found for overweight ( = 0.129) or obese ( = 0.166) patients compared to normal weight. However, higher OM rates were recorded in overweight (hazard ratio [HR] 3.59, 95% CI: 1.03-12.51,  = 0.044), as well as in obese, patients (HR 7.83, 95% CI: 2.20-27.83,  = 0.002). Similarly, higher DR rates were recorded in obese (HR 2.76, 95% CI: 1.40-5.44,  = 0.003) patients. Obese and overweight patients do not experience higher complication rates or worse eGFR after minimally invasive kidney surgery, which therefore can be deemed feasible and safe also in this subset of patients. Nevertheless, obese and overweight patients seem to carry a higher risk of OM, and therefore, they should undergo a strict follow-up after surgery.
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http://dx.doi.org/10.1089/end.2019.0604DOI Listing
March 2020

Risk Factors for Upstaging, Recurrence, and Mortality in Clinical T1-2 Renal Cell Carcinoma Patients Upstaged to pT3a Disease: An International Analysis Utilizing the 8th Edition of the Tumor-Node-Metastasis Staging Criteria.

Urology 2020 Apr 11;138:60-68. Epub 2019 Dec 11.

Department of Urology, University of California San Diego School of Medicine, La Jolla, California. Electronic address:

Objective: To investigate risk factors for and outcomes in pathological T3a-upstaging in Renal Cell Carcinoma (RCC), as Tumor-Node-Metastasis staging for T3a RCC was recently revised.

Methods: Multicenter retrospective analysis of patients with clinical T1-T2 RCC, stratified by occurrence of pathologic T3a-upstaging. Primary outcome was recurrence-free survival (RFS). Multivariable analyses (MVA) were conducted for upstaging and recurrence. Kaplan-Meier analysis (KMA) was utilized for RFS and overall survival (OS).

Results: We analyzed 2573 patients (1223 RN/1350 PN). Upstaging occurred in 360 (14.0%). On MVA, higher clinical stage was associated with increasing risk of upstaging [cT1a (referent), odds ratio for cT1b, cT2a, and cT2b was 2.6, 6.5, and 14.1, P < .001]. Higher clinical stage at presentation correlated with increasing risk of recurrence in pT3a-upstaged RCC (cT1a upstaged-pT3a [referent], hazard ratio [HR] for cT1b, cT2a, and cT2b upstaged pT3a was 1.16 [P = .729], 3.02 [P = .013], and 4.5 [P = .003]). Perirenal fat (HR 1.6, P = .038) and renal vein (HR 2.2, P = .006) invasion were associated with increased risk of recurrence; type of surgery was not (P = .157). KMA for RFS and OS in pT3a-upstaged patients demonstrated differences based on initial clinical stage (5-year PFS for cT1a/b, and cT2 upstaged was 84.5%/72.8%, and 44.7%, P < .001; 5-year OS for cT1 and cT2 upstaged was 83.8% and 63.2%, P < .001).

Conclusion: Risk of pT3a-upstaging and recurrence in pT3a-upstaged RCC correlates with clinical stage at presentation. Renal vein and perinephric fat invasion were associated with increased risk of recurrence. PN did not increase risk of recurrence and potential of pT3a-upstaging should not deter consideration of PN.
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http://dx.doi.org/10.1016/j.urology.2019.11.036DOI Listing
April 2020

Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology.

J Natl Compr Canc Netw 2019 12;17(12):1529-1554

28National Comprehensive Cancer Network.

Testicular cancer is relatively uncommon and accounts for <1% of all male tumors. However, it is the most common solid tumor in men between the ages of 20 and 34 years, and the global incidence has been steadily rising over the past several decades. Several risk factors for testicular cancer have been identified, including personal or family history of testicular cancer and cryptorchidism. Testicular germ cell tumors (GCTs) comprise 95% of malignant tumors arising in the testes and are categorized into 2 main histologic subtypes: seminoma and nonseminoma. Although nonseminoma is the more clinically aggressive tumor subtype, 5-year survival rates exceed 70% with current treatment options, even in patients with advanced or metastatic disease. Radical inguinal orchiectomy is the primary treatment for most patients with testicular GCTs. Postorchiectomy management is dictated by stage, histology, and risk classification; treatment options for nonseminoma include surveillance, systemic therapy, and nerve-sparing retroperitoneal lymph node dissection. Although rarely occurring, prognosis for patients with brain metastases remains poor, with >50% of patients dying within 1 year of diagnosis. This selection from the NCCN Guidelines for Testicular Cancer focuses on recommendations for the management of adult patients with nonseminomatous GCTs.
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http://dx.doi.org/10.6004/jnccn.2019.0058DOI Listing
December 2019

Predictive Value of Nephrometry Scores in Nephron-sparing Surgery: A Systematic Review and Meta-analysis.

Eur Urol Focus 2020 05 24;6(3):490-504. Epub 2019 Nov 24.

Division of Urology, VCU Health System, Richmond, VA, USA. Electronic address:

Context: Over the last decade, several nephrometry scores (NSs) have been introduced with the aim of facilitating preoperative decision making, planning, and counseling in the field of nephron-sparing surgery. However, their predictive role remains controversial.

Objective: To describe currently available nephrometry scores and to determine their predictive role for different outcomes by performing a systematic review and meta-analysis of the literature.

Evidence Acquisition: PubMed, Embase®, and Web of Science were screened to identify eligible studies. Identification and selection of the reports were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). A pooled analysis of NS predictive role of intraoperative, postoperative, oncological, and functional outcomes was performed. Odds ratio was considered the effect size. All the analyses were performed using Stata 15.0, and statistical significance was set at p≤ 0.05.

Evidence Synthesis: Overall, 51 studies meeting our inclusion criteria were identified and considered for the analysis. Except for one prospective randomized trial, all the studies were retrospective. All the studies were found to be of intermediate quality, except for one of high quality. Most studies assessed the predictive role of the Radius-Exophytic/Endophytic-Nearness-Anterior/Posterior-Location (RENAL) and Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) scores, mostly regarding complications after nephron-sparing surgery. RENAL was an independent predictor of an on-clamp procedure (p< 0.001). Mayo Adhesive Probability score was related to adhesive perinephric fat (p= 0.005). Continuous and high-complexity RENAL scores were predictors of warm ischemia time (WIT; p= 0.006 and p< 0.001, respectively). Continuous (p< 0.001) and high-complexity (p< 0.001) PADUA scores were related to WIT. Continuous and high-complexity RENAL scores were predictors of overall complications (p= 0.002 and p< 0.001, respectively). PADUA score was related to complications both as continuous (p< 0.001) and as a categorical value (p< 0.002). The RENAL scores R=3 (p= 0.008), E=2 (p= 0.039), and hilar location (p= 0.006) were predictors of histological malignancy. Continuous and categorical RENAL scores were independent predictors of an estimated glomerular filtration rate (eGFR) increase (p= 0.006 and p< 0.001, respectively). The Diameter-Axial-Polar score (p= 0.018) and Peritumoral Artery Scoring System (PASS; p= 0.02) were also independent predictors.

Conclusions: The literature regarding nephrometry scoring systems is sparse, and mostly focused on RENAL and PADUA, which are easy to calculate and have a good correlation with most outcomes. Renal Pelvic Score is the best predictor of pelvicalyceal entry/repair and urine leak, whereas Surgical Approach Renal Ranking and PASS strongly predict surgical approach and renal function variation, respectively. Other nephrometry scores based on mathematical models are limited by their complexity, and they lack evidence supporting their predictive value.

Patient Summary: We reviewed the medical literature regarding the use and value of so-called "nephrometry scores," which are scoring systems based on radiological imaging and made to grade the complexity of a renal tumor. We analyzed whether these scoring systems can predict some of the outcomes of patients undergoing surgical removal of renal tumors.
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http://dx.doi.org/10.1016/j.euf.2019.11.004DOI Listing
May 2020

Robotic partial nephrectomy for clinical T2a renal mass is associated with improved trifecta outcome compared to open partial nephrectomy: a single surgeon comparative analysis.

World J Urol 2020 May 8;38(5):1113-1122. Epub 2019 Nov 8.

Department of Urology, UC San Diego School of Medicine, 9400 Campus Point Drive, Mail Code 7897, La Jolla, CA, 92093-7897, USA.

Objective: Utilization of partial nephrectomy (PN) for T2 renal mass is controversial due to concerns regarding burden of morbidity, though most cited data are from open PN (OPN). We compared surgical quality and functional outcomes of RPN and OPN for clinical T2a renal masses (cT2aRM).

Methods: Retrospective analysis of 150 consecutive patients [RPN 59/OPN 91] who underwent PN from July 2008 to June 2016. Main outcome was achievement of Trifecta [negative surgical margin, no major urologic complications, and ≥90% preservation of estimated glomerular filtration rate (eGFR)]. Multivariable analysis was performed to identify factors of Trifecta attainment.

Results: Mean tumor size (RPN 7.9 vs. OPN 8.4 cm, p = 0.139) and median RENAL score (p = 0.361) were similar. No difference was noted for positive margins (RPN 3.4% vs. OPN 1.1%, p = 0.561), ΔeGFR (RPN - 6.2 vs. OPN - 7.8, p = 0.543), and ≥ 90% eGFR recovery (RPN 54.1% vs. OPN 47.2%, p = 0.504). RPN had lower blood loss (p = 0.015), hospital stay (p = 0.013), and Clavien ≥ 3 complications (RPN 5.1% vs. OPN 16.5%, p = 0.041). Trifecta rate was significantly higher in RPN (47.5% vs. 34.0%, p = 0.041). Multivariable analysis demonstrated decreasing RENAL score (OR 1.11, p < 0.001), RPN (OR 1.2, p = 0.013), and decreasing EBL (OR 1.02, p = 0.016) to be associated with Trifecta attainment.

Conclusions: RPN provided similar functional and oncologic precision to OPN, while being associated with improvements in major complications, the latter of which was reflected in a higher rate of Trifecta achievement for RPN. RPN may be considered to be a first-line option for select patients with cT2aRM when feasible and safe.
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http://dx.doi.org/10.1007/s00345-019-02994-2DOI Listing
May 2020