Publications by authors named "Ketan K Badani"

136 Publications

Immunotherapy for metastatic renal cell carcinoma: A brief history, current trends, and future directions.

Urol Oncol 2021 Jul 23. Epub 2021 Jul 23.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Recent innovations in systemic therapy for metastatic renal cell carcinoma (mRCC) have occurred at a break-neck pace. In the 1980s, nontargeted cytokine-mediated immunotherapy was the systemic therapy of choice. Based on improvements in tolerability and patient outcomes, targeted antiangiogenic agents supplanted cytokines in the early 2000s. During the last decade, the most recent innovation has come in the form of immune-checkpoint inhibitors (ICIs), a form of immunotherapy that enhances immune-mediated tumor cell destruction. ICIs improve on all prior iterations of systemic therapies and have become the first-line therapy for many mRCC indications. ICIs have been shown to increase overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and complete response rate (CRR) in mRCC patients. We reviewed the recent trends associated with ICI management of mRCC, their immune-related adverse events, and cost implications.
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http://dx.doi.org/10.1016/j.urolonc.2021.06.013DOI Listing
July 2021

Comparison of Perioperative Outcomes for Radical Nephrectomy Based on Surgical Approach for Masses Greater than 10cm.

J Endourol 2021 Jun 19. Epub 2021 Jun 19.

UCI, 8788, 333 City Blvd. West, Suite 2100, Orange, California, United States, 92868.

Introduction and Objective Robotic-assisted radical nephrectomy (RRN) is increasingly utilized as an alternative to laparoscopic radical nephrectomy (LRN) but there are concerns over costs and objective benefit. In the setting of very large renal masses (>10 cm), comparison between techniques is limited and it is unclear whether a robotic approach confers any perioperative benefit over LRN or open radical nephrectomy (ORN). In this study, perioperative outcomes of RRN, LRN, and ORN for very large renal masses are compared. Methods Using the National Cancer Database, patients were identified who underwent radical nephrectomy for kidney tumors >10 cm diagnosed from 2010-2015. Patients were analyzed according to surgical approach. Perioperative outcomes, including conversion to open, length of stay, readmission rates, positive surgical margins, and 30 and 90-day mortality were compared among cohorts. Results A total of 9288 patients met inclusion criteria (RRN = 842, LRN = 2326, ORN = 6120). Compared to ORN, recipients of RRN or LRN had similar rates of 30-day readmission and 30- and 90-day mortality. Length of hospital stay was significantly shorter in RRN (-1.73 days ±0.19; p<0.0001) and LRN (-1.40 days ±0.12; p<0.0001) compared to ORN. LRN had a higher rate of conversion to open compared to RRN (OR 1.48; 95% CI 1.10-1.98; p=0.0087). Conversion to open from RRN or LRN added 1.3 additional days of inpatient stay. Over the study period, RRN use increased from 4.1% to 14.8%, LRN from 20.9% to 25.6%, while ORN use decreased from 75% to 59.6%. Conclusions Minimally invasive approaches are increasingly utilized in very large renal masses. RRN has lower rates of conversion to open but produces comparable perioperative outcomes to LRN. Minimally invasive approaches have a shorter length of inpatient stay but otherwise report similar surgical margin status, readmission rates, and mortality rates compared to open radical nephrectomy.
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http://dx.doi.org/10.1089/end.2020.1164DOI Listing
June 2021

Salvage Robot-assisted Renal Surgery for Local Recurrence After Surgical Resection or Renal Mass Ablation: Classification, Techniques, and Clinical Outcomes.

Eur Urol 2021 Jun 1. Epub 2021 Jun 1.

Department of Urology, Vita-Salute San Raffaele University, Milan, Italy. Electronic address:

Background: Salvage treatment for local recurrence after prior partial nephrectomy (PN) or local tumor ablation (LTA) for kidney cancer is, as of yet, poorly investigated.

Objective: To classify the treatments and standardize the nomenclature of salvage robot-assisted renal surgery, to describe the surgical technique for each scenario, and to investigate complications, renal function, and oncologic outcomes.

Design, Setting, And Participants: Sixty-seven patients underwent salvage robot-assisted renal surgery from October 2010 to December 2020 at nine tertiary referral centers.

Surgical Procedure: Salvage robot-assisted renal surgery classified according to treatment type as salvage robot-assisted partial or radical nephrectomy (sRAPN or sRARN) and according to previous primary treatment (PN or LTA).

Measurements: Postoperative complications, renal function, and oncologic outcomes were assessed.

Results And Limitations: A total of 32 and 35 patients underwent salvage robotic surgery following PN and LTA, respectively. After prior PN, two patients underwent sRAPN, while ten underwent sRARN for a metachronous recurrence in the same kidney. No intra- or perioperative complication occurred. For local recurrence in the resection bed, six patients underwent sRAPN, while 14 underwent sRARN. For sRAPN, the intraoperative complication rate was 33%; there was no postoperative complication. For sRARN, there was no intraoperative complication and the postoperative complication rate was 7%. At 3 yr, the local recurrence-free rates were 64% and 82% for sRAPN and sRARN, respectively, while the 3-yr metastasis-free rates were 80% and 79%, respectively. At 33 mo, the median estimated glomerular filtration rates (eGFRs) were 57 and 45 ml/min/1.73 m for sRAPN and sRARN, respectively. After prior LTA, 35 patients underwent sRAPN and no patient underwent sRARN. There was no intraoperative complication; the overall postoperative complications rate was 20%. No local recurrence occurred. The 3-yr metastasis-free rate was 90%. At 43 mo, the median eGFR was 38 ml/min/1.73 m. The main limitations are the relatively small population and the noncomparative design of the study.

Conclusions: Salvage robot-assisted surgery has a safe complication profile in the hands of experienced surgeons at high-volume institutions, but the risk of local recurrence in this setting is non-negligible.

Patient Summary: Patients with local recurrence after partial nephrectomy or local tumor ablation should be aware that further treatment with robot-assisted surgery is not associated with a worrisome complication profile, but also that they are at risk of further recurrence.
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http://dx.doi.org/10.1016/j.eururo.2021.04.003DOI Listing
June 2021

Comparison of 1-Year Health Care Costs and Use Associated With Open vs Robotic-Assisted Radical Prostatectomy.

JAMA Netw Open 2021 03 1;4(3):e212265. Epub 2021 Mar 1.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York.

Importance: With the current patterns of adoption and use of robotic surgery and improvement in the overall survival of patients with prostate cancer, it is important to evaluate the immediate and long-term cost implications of treatments for patients with prostate cancer.

Objective: To compare health care costs and use 1 year after open radical prostatectomy (ORP) vs robotic-assisted radical prostatectomy (RARP).

Design, Setting, And Participants: This retrospective cohort study used a US commercial claims database from January 1, 2013, to December 31, 2018. A total of 11 457 men aged 18 to 64 years who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after inpatient prostatectomy were identified. An inverse probability of treatment weighting analysis was performed to examine the differences in costs and use of health care services by surgical modality. Data analysis was conducted from September 2019 to July 2020.

Exposures: Type of surgical procedure: ORP vs RARP.

Main Outcomes And Measures: Three outcomes within 1 year after the inpatient prostatectomy were investigated: (1) total health care costs, including reimbursement paid by insurers and out of pocket by patients; (2) health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and (3) estimated days missed from work due to health care use.

Results: Of the 11 457 patients who underwent inpatient prostatectomy, 1604 (14.0%) had ORP and 9853 (86.0%) had RARP and most patients (8467 [73.9%]) were aged 55 to 64 years. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (mean difference, $2367; 95% CI, $1821-$2914; P < .001), but similar total cumulative costs were observed within 180 days (mean difference, $397; 95% CI, -$582 to $1375; P = .43) and 1 year after discharge (-$383; 95% CI, -$1802 to $1037; P = .60). One-year postdischarge health care use was significantly lower in the RARP compared with ORP group for mean numbers of emergency department visits (-0.09 visits; 95% CI, -0.11 to -0.07 visits; P < .001) and hospital outpatient visits (-1.5 visits; -1.63 to -1.36 visits; P < .001). The reduction in use of health care services among patients who underwent RARP translated into additional savings of $2929 (95% CI, $1600-$4257; P < .001) and approximately 1.69 fewer days (95% CI, 1.49-1.89 days; P < .001) missed from work for health care visits.

Conclusions And Relevance: Total cumulative cost in this study was similar between ORP and RARP 1 year post discharge; this finding suggests that lower postdischarge health care use after RARP may offset the higher costs during the index hospitalization.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.2265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985723PMC
March 2021

Cancer, Mortality, and Acute Kidney Injury among Hospitalized Patients with SARS-CoV-2 Infection.

Asian Pac J Cancer Prev 2021 Feb 1;22(2):517-522. Epub 2021 Feb 1.

Department of Urology, Ichan School of Medicine at Mount Sinai, New York, NY, USA.

Background: To evaluate Coronavirus Disease 2019-(COVID19) patients treated within our academic medical system to determine if history of malignancy, both in general and specifically in genitourinary oncology patients, is associated with adverse clinical outcomes, including acute kidney injury (AKI) and mortality.

Methods: We conducted a retrospective cohort study among patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a multi-hospital, academic medical institution in New York City. Outcomes included mortality, intensive care unit (ICU) admission and AKI among hospitalized patients. We also evaluated risk of hospitalization among all patients with SARS-CoV-2 infection. Multilevel logistic regression models were used for analysis.

Results: We identified 6,893 patients who met inclusion criteria, of which 4,018 were hospitalized. Among hospitalized patients 374 (9%) had a history of cancer, 281 (7%) experienced AKI, and 1,045 (26%) died. In adjusted analyses, patients with a history of cancer had 1.33 (95% CI = 1.05, 1.69) times the odds of death compared to those without cancer and this appeared to be driven by lung cancer (odds ratio (OR) = 2.44, 95% CI= 1.05, 4.39). Patients with a history of genitourinary cancer were not at higher risk of mortality compared to those without cancer (OR=0.99, 95% CI= 0.61, 1.62). History of cancer was not associated with ICU admission or AKI in overall and subgroup analyses.

Conclusions: Patients with a history of cancer who are hospitalized with SARS-CoV-2 infection are not at greater risk for AKI, though they are at higher risk for mortality as compared to patients without a history of cancer. The increased risk in mortality appears driven by patients with pulmonary neoplasms. Patients with a history of genitourinary malignancies do not appear to be at higher risk for AKI or for mortality compared to the general population.
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http://dx.doi.org/10.31557/APJCP.2021.22.2.517DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190375PMC
February 2021

Association between chronic kidney disease and COVID-19-related mortality in New York.

World J Urol 2021 Jan 22. Epub 2021 Jan 22.

Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425, Madison Ave, New York, NY, 10029, USA.

Purpose: To evaluate mortality risk of CKD patients infected with COVID-19, and assess shared characteristics associated with health disparities in CKD outcome.

Methods: We extracted the data from a case series of 7624 patients presented at Mount Sinai Health System, in New York for testing between 3/28/2020 and 4/16/2020. De-identified patient data set is being produced by the Scientific Computing department and made available to the Mount Sinai research community at the following website: https://msdw.mountsinai.org/ .

Results: Of 7624 COVID-19 patients, 7.8% (n = 597) had CKD on hospital admission, and 11.2% (n = 856) died of COVID-19 infection. CKD patients were older, more likely to have diabetes, hypertension, and chronic obstructive pulmonary disease (COPD), were current or former smokers, had a longer time to discharge, and had worse survival compared to non-CKD patients (p < 0.05). COVID-19 mortality rate was significantly higher in CKD patients (23.1% vs 10.2%) with a 1.51 greater odds of dying (95% CI: 1.19-1.90). Controlling for demographic, behavioral, and clinical covariates, the logistic regression analysis showed significant and consistent effects of CKD, older age, male gender, and hypertension with mortality (p < 0.05).

Conclusion: CKD was a significant independent predictor of COVID-19 mortality, along with older age, male gender, and hypertension. Future research will investigate the effects of COVID-19 on long-term renal function.
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http://dx.doi.org/10.1007/s00345-020-03567-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7821175PMC
January 2021

The role of RENAL score in predicting complications after robotic partial nephrectomy.

Minerva Urol Nefrol 2021 Jan 13. Epub 2021 Jan 13.

Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA -

Background: The aim of this study is to evaluate the association between tumor complexity based on RENAL nephrometry score and complications.

Methods: We retrospectively identified 2555 patients who underwent RPN for renal cell carcinoma. Major complication was defined as clavien grade≥3. The relationship between baseline demographic, clinical characteristics, perioperative and postoperative outcomes, and tumor complexity were assessed using Chi-square test of independence, Fishers exact and Kruskal Wallis test. An unadjusted and adjusted logistic regression model was used to assess the relationship between major complication and demographic, clinical characteristics, and perioperative outcomes.

Results: There was a significant relationship between tumor complexity and WIT(p<0.001), operative time(p<0.001), estimated blood loss (p<0.001), and major complication(p=0.019). However, there was no relationship with overall complications(p=0.237) and length of stay (LOS) (p=0.085). In the unadjusted model, higher tumor complexity was associated with major complication (p=0.009). Controlling for other variables, there was no significant difference between major complication and tumor complexity (low vs. moderate, p=0.142 and high, p=0.204). LOS (p <0.001) and operative time (p=0.025) remained a significant predictor of major complication in the adjusted model.

Conclusions: Tumor complexity is not associated with an increase in overall or major complication rate after RPN. Experience in high-volume centers is demonstrating a standardization of low complications rates after RPN independent of tumor complexity.
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http://dx.doi.org/10.23736/S0393-2249.20.03608-5DOI Listing
January 2021

Black race may be associated with worse overall survival in renal cell carcinoma patients.

Urol Oncol 2020 12 17;38(12):938.e9-938.e17. Epub 2020 Sep 17.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Objective: To examine socio-demographic and treatment variables in an attempt to identify factors associated with survival differences between black and white patients with renal cell carcinoma (RCC).

Patients And Methods: We identified 79,618 white and 10,604 black patients diagnosed with RCC in the National Cancer Database. We compared the distribution of socio-demographic, presentation and treatment variables between Blacks and Whites and then utilized a multivariable cox proportion hazards regression model to evaluate the contribution of differences in these variables to disparities in overall survival (OS).

Results: Black patients were younger (60 vs. 63 years, P< 0.001) and with a lower stage (12.0% vs. 18.8% Stage III-IV P< 0.001). Blacks presented with a higher Charlson-Deyo score (P< 0.001), lower income (P< 0.001), lower education (P< 0.001) and were less likely to receive radical nephrectomy and systemic therapy for stage IV RCC (29.9% vs. 38.8%, P< 0.001). Unadjusted OS was lower for Whites (5-year survival 79% for Blacks and 77% for Whites). However, OS was lower for Blacks when adjusted for all variables (5-year survival 89% for Blacks and 93% for Whites). On multivariable analysis, black race was independently associated with worse OS, HR: 1.09 (95% confidence interval: 1.03, 1.14, P= 0.002). A sensitivity analysis including patients with complete data on tumor grade confirmed our results.

Conclusion: Our study indicates that black patients present at a younger age and with lower stage RCC, but have worse OS. Blacks experienced disparities in socio-demographic characteristics, clinical presentation, treatment-related factors, and had an independently increased hazard of death.
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http://dx.doi.org/10.1016/j.urolonc.2020.08.034DOI Listing
December 2020

Repurposing of α1-Adrenoceptor Antagonists: Impact in Renal Cancer.

Cancers (Basel) 2020 Aug 28;12(9). Epub 2020 Aug 28.

Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.

Renal cancer ranks twelfth in incidence among cancers worldwide. Despite improving outcomes due to better therapeutic options and strategies, prognosis for those with metastatic disease remains poor. Current systemic therapeutic approaches include inhibiting pathways of angiogenesis, immune checkpoint blockade, and mTOR inhibition, but inevitably resistance develops for those with metastatic disease, and novel treatment strategies are urgently needed. Emerging molecular and epidemiological evidence suggests that quinazoline-based α1-adrenoceptor-antagonists may have both chemopreventive and direct therapeutic actions in the treatment of urological cancers, including renal cancer. In human renal cancer cell models, quinazoline-based α1-adrenoceptor antagonists were shown to significantly reduce the invasion and metastatic potential of renal tumors by targeting focal adhesion survival signaling to induce anoikis. Mechanistically these drugs overcome anoikis resistance in tumor cells by targeting cell survival regulators AKT and FAK, disrupting integrin adhesion (α5β1 and α2β1) and engaging extracellular matrix (ECM)-associated tumor suppressors. In this review, we discuss the current evidence for the use of quinazoline-based α1-adrenoceptor antagonists as novel therapies for renal cell carcinoma (RCC) and highlight their potential therapeutic action through overcoming anoikis resistance of tumor epithelial and endothelial cells in metastatic RCC. These findings provide a platform for future studies that will retrospectively and prospectively test repurposing of quinazoline-based α1-adrenoceptor-antagonists for the treatment of advanced RCC and the prevention of metastasis in neoadjuvant, adjuvant, salvage and metastatic settings.
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http://dx.doi.org/10.3390/cancers12092442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564811PMC
August 2020

The Resilient Child: Sex-Steroid Hormones and COVID-19 Incidence in Pediatric Patients.

J Endocr Soc 2020 Sep 28;4(9):bvaa106. Epub 2020 Jul 28.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York.

Coronavirus disease-2019 (COVID-19), a disease caused by Severe Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, has become an unprecedented global health emergency, with fatal outcomes among adults of all ages in the United States, and the highest incidence and mortality in adult men. As the pandemic evolves there is limited understanding of a potential association between symptomatic viral infection and age. To date, there is no knowledge of the role children (prepubescent, ages 9-13 years) play as "silent" vectors of the virus, with themselves being asymptomatic. Throughout different time frames and geographic locations, the current evidence on COVID-19 suggests that children are becoming infected at a significantly lower rate than other age groups-as low as 1%. Androgens upregulate the protease TMPRSS2 (type II transmembrane serine protease-2), which facilitates efficient virus-host cell fusion with the epithelium of the lungs, thus increasing susceptibility to SARS-CoV-2 infection and development of severe COVID-19. Owing to low levels of steroid hormones, prepubertal children may have low expression of TMPRSS2, thereby limiting the viral entry into host cells. As the world anticipates a vaccine against SARS-CoV-2, the role of prepubescent children as vectors transmitting the virus must be interrogated to prepare for a potential resurgence of COVID-19. This review discusses the current evidence on the low incidence of COVID-19 in children and the effect of sex-steroid hormones on SARS-CoV-2 viral infection and clinical outcomes of pediatric patients. On reopening society at large, schools will need to implement heightened health protocols with the knowledge that children as the "silent" viral transmitters can significantly affect the adult populations.
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http://dx.doi.org/10.1210/jendso/bvaa106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7448286PMC
September 2020

Measuring volumetric segmentation changes in the ipsilateral and contralateral kidney postpartial nephrectomy.

Urol Oncol 2020 10 29;38(10):798.e1-798.e7. Epub 2020 Jul 29.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY. Electronic address:

Objective: To analyze the volumetric changes of the ipsilateral and contralateral kidneys and their effect on functional outcome post partial nephrectomy using segmentation analysis.

Patients And Methods: We have analyzed the data of 119 patients from a single surgeon series of partial nephrectomy patients. Median follow-up was 11.40 months. Patients with bilateral tumors, and solitary kidney were excluded from analysis. Volumetric measurements were performed using a semiautomated tissue segmentation tool. A simple linear regression model to assess the predictors for parenchymal volume loss (PVL). A multivariable linear regression model was used to evaluate the association between PVL and warm ischemia time (WIT), controlling for other factors.

Results: Mean WIT was 12.09 ± 4.40 minutes and the mean percentage decrease in the volume of the operated kidney was 16.99 ± 13.49%. WIT (β = 1.24, P < 0.001) and tumor complexity (simple vs. intermediate, β = 0.06, P = 0.984; simple vs. high, β = 11.62,P = 0.007) were associated with PVL. A 1 minute increase in WIT was associated with an increase in the percentage volume loss in the operated kidney by 1.38% (β = 1.20, P < 0.001). Patients with high tumor complexity (β = 11.17, P = 0.009) had a significantly higher percentage volume loss compared to patients with simple tumor complexity. Ipsilateral PVL (β = -0.35, P = 0.015) and male gender (β = -9.89, P = 0.021) were associated with change in eGFR. After adjusting for confounders, % volume loss (β = -0.32, P < 0.001) remained a significant predictor for contralateral hypertrophy.

Conclusion: Tumor complexity results in higher WIT and increased PVL as measured by volumetric segmentation. PVL is a key factor associated with functional outcome, and is directly linked to WIT. Increased PVL is also associated with decreased contralateral hypertrophy. Prospective studies with larger samples sizes will be required to validate our findings.
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http://dx.doi.org/10.1016/j.urolonc.2020.05.016DOI Listing
October 2020

Urologic oncology practice during COVID-19 pandemic: A systematic review on what can be deferrable vs. nondeferrable.

Urol Oncol 2020 10 26;38(10):783-792. Epub 2020 Jun 26.

Department of Urology, Division of Urologic Oncology, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Purpose: To provide a review of high-risk urologic cancers and the feasibility of delaying surgery without impacting oncologic or mortality outcomes.

Materials And Methods: A thorough literature review was performed using PubMed and Google Scholar to identify articles pertaining to surgical delay and genitourinary oncology. We reviewed all relevant articles pertaining to kidney, upper tract urothelial cell, bladder, prostate, penile, and testicular cancer in regard to diagnostic, surgical, or treatment delay.

Results: The majority of urologic cancers rely on surgery as primary treatment. Treatment of unfavorable intermediate or high-risk prostate cancer, can likely be delayed for 3 to 6 months without affecting oncologic outcomes. Muscle-invasive bladder cancer and testicular cancer can be treated initially with chemotherapy. Surgical management of T3 renal masses, high-grade upper tract urothelial carcinoma, and penile cancer should not be delayed.

Conclusion: The majority of urologic oncologic surgeries can be safely deferred without impacting long-term cancer specific or overall survival. Notable exceptions are muscle-invasive bladder cancer, high-grade upper tract urothelial cell, large renal masses, testicular and penile cancer. Joint decision making among providers and patients should be encouraged. Clinicians must manage emotional anxiety and stress when decisions around treatment delays are necessary as a result of a pandemic.
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http://dx.doi.org/10.1016/j.urolonc.2020.06.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318929PMC
October 2020

Should a Drain Be Routinely Required After Transperitoneal Robotic Partial Nephrectomy?

J Endourol 2020 09 25;34(9):964-968. Epub 2020 Aug 25.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Closed drains have traditionally been placed after partial nephrectomy because of risks of bleeding and urine leak. We sought to study the safety of a nonroutine drain (NRD) approach after transperitoneal robotic partial nephrectomy (RPN). From a multi-institutional database, we have analyzed the data of 904 patients who underwent RPN. Five hundred forty-six (60.40%) patients underwent RPN by a surgeon who routinely placed drains. Three hundred fifty-eight (39.60%) patients underwent RPN by a surgeon who did not routinely placed drains. Perioperative outcomes, length of stay (LOS), and readmission rates were compared between the two groups. Baseline characteristics, perioperative, and postoperative outcomes were compared using Mann-Whitney U test, chi-square test, and Fisher's exact test. Patients in the NRD group were more likely to have higher body mass index (30.10 kg/m 28.07 kg/m;  < 0.001), higher tumor size (3.0 cm 2.5 cm;  = 0.001), and higher renal score (8 7;  < 0.001). Rate of transfusion (0.00% NRD 0.56% RD;  = 0.157) and overall complication (7.33% NRD 7.82% RD;  = 0.782) were comparable. Median hospital stay is 1 day for both groups. Readmission rate was also similar (0.55% NRD 1.40% RD;  = 0.279). In a multivariable analysis, NRD approach was associated with shorter length of hospital stay (incidence rate ratio [IRR] - 0.72,  < 0.001). An NRD approach for RPN yielded a decreased LOS and similar perioperative outcomes. Placement of surgical drains should be based on individual circumstances, and not required on a routine basis.
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http://dx.doi.org/10.1089/end.2020.0325DOI Listing
September 2020

Epithelial plasticity can generate multi-lineage phenotypes in human and murine bladder cancers.

Nat Commun 2020 05 21;11(1):2540. Epub 2020 May 21.

Division of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, 10029, USA.

Tumor heterogeneity is common in cancer, however recent studies have applied single gene expression signatures to classify bladder cancers into distinct subtypes. Such stratification assumes that a predominant transcriptomic signature is sufficient to predict progression kinetics, patient survival and treatment response. We hypothesize that such static classification ignores intra-tumoral heterogeneity and the potential for cellular plasticity occurring during disease development. We have conducted single cell transcriptome analyses of mouse and human model systems of bladder cancer and show that tumor cells with multiple lineage subtypes not only cluster closely together at the transcriptional level but can maintain concomitant gene expression of at least one mRNA subtype. Functional studies reveal that tumor initiation and cellular plasticity can initiate from multiple lineage subtypes. Collectively, these data suggest that lineage plasticity may contribute to innate tumor heterogeneity, which in turn carry clinical implications regarding the classification and treatment of bladder cancer.
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http://dx.doi.org/10.1038/s41467-020-16162-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242345PMC
May 2020

Does race impact functional outcomes in patients undergoing robotic partial nephrectomy?

Transl Androl Urol 2020 Apr;9(2):863-869

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Background: The role of race on functional outcomes after robotic partial nephrectomy (RPN) is still a matter of debate. We aimed to evaluate the clinical and pathologic characteristics of African American (AA) and Caucasian patients who underwent RPN and analyzed the association between race and functional outcomes.

Methods: Data was obtained from a multi-institutional database of patients who underwent RPN in 6 institutions in the USA. We identified 999 patients with complete clinical data. Sixty-three patients (6.3%) were AA, and each patient was matched (1:3) to Caucasian patients by age at surgery, gender, Charlson Comorbidity Index (CCI) and renal score. Bivariate and multivariate logistic regression analyses were used to evaluate predictors of acute kidney injury (AKI). Kaplan-Meier method and multivariable semiparametric Cox regression analyses were performed to assess prevalence and predictors of significant eGFR reduction during follow-up.

Results: Overall, 252 patients were included. AA were more likely to have hypertension (58.7% 35.4%, P=0.001), even after 1:3 match. Overall 42 patients (16.7%) developed AKI after surgery and 35 patients (13.9%) developed significant eGFR reduction between 3 and 15 months after RAPN. On multivariate analysis, AA race did not emerge as a significant factor for predicting AKI (OR 1.10, P=0.8). On Cox multivariable analysis, only AKI was found to be associated with significant eGFR reduction between 3 and 15 months after RAPN (HR 2.49, P=0.019).

Conclusions: Although African American patients were more likely to have hypertension, renal function outcomes of robotic partial nephrectomies were not significantly different when stratified by race. However, future studies with larger cohorts are necessary to validate these findings.
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http://dx.doi.org/10.21037/tau.2019.09.31DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214979PMC
April 2020

Selective clamping during robot-assisted partial nephrectomy in patients with a solitary kidney: is it safe and does it help?

BJU Int 2020 06 27;125(6):893-897. Epub 2020 Mar 27.

Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA.

Objectives: To obtain the most accurate assessment of the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN) we evaluated outcomes of this technique vs those of full clamping in patients with a solitary kidney undergoing RAPN.

Patients And Methods: Data from institutional review board-approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analysed with regard to demographics, risk factors, intra-operative complications, and postoperative outcomes using chi-squared tests, Fisher's exact tests, t-tests and Mann-Whitney U-tests.

Results: Our initial cohort consisted of 4112 patients, of whom 72 had undergone RAPN in a solitary kidney (51 with full clamping and 21 with selective clamping). There were no significant differences in demographics, tumour size, baseline estimated glomerular filtration rate (eGFR), or warm ischaemia time (WIT) between the groups (Table 1). Intra-operative outcomes, including estimated blood loss, operating time, and intra-operative complications were similar in the two groups. Short- and long-term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques.

Conclusion: In a large cohort of patients with solitary kidney undergoing RAPN, selective clamping resulted in similar intra-operative and postoperative outcomes compared to full clamping and conferred no additional risk of harm. However, selective clamping did not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15 min) may have prevented identification of benefits in the selective clamping group; a similar study analysing cases with longer WIT may elucidate any beneficial effects of selective clamping.
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http://dx.doi.org/10.1111/bju.15043DOI Listing
June 2020

Robotic partial nephrectomy: The current status.

Indian J Urol 2020 Jan-Mar;36(1):16-20

Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA.

Introduction: Since its introduction, robotic partial nephrectomy (RPN) has become increasingly popular, in part as a result of several advances in technique. The purpose of this paper is to review these techniques as well as the perioperative, functional, and oncologic outcomes after RPN and compare these outcomes to those after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).

Methods: A literature review was performed to identify papers and meta-analyses that compared outcomes after RPN to OPN or LPN. All meta-analyses were included in this review.

Results: Technical advances that have contributed to improved outcomes after RPN include the first-assistant sparing technique, the sliding clip technique, early unclamping, and selective arterial clamping. All five meta-analyses that compared LPN to RPN found that RPN was associated with a shorter warm ischemia time (WIT), but that there were no differences in estimated blood loss (EBL) or operative times. Those meta-analyses that compared intraoperative and postoperative complications, conversion to open or radical nephrectomy, length of stay (LOS), and postoperative estimated glomerular filtration rate (eGFR) either found no difference or favored RPN. Four meta-analyses compared RPN to OPN. All four found that EBL, LOS, and postoperative complications favor RPN. There were no significant differences in intraoperative complications, conversion to radical nephrectomy, or positive surgical margin rates. One meta-analysis found that eGFR was better after RPN. Operative time and WIT generally favored OPN.

Conclusions: Several techniques have been described to improve outcomes after RPN. We believe that the literature shows that RPN is as good if not better than both LPN and OPN and has become the preferred surgical approach.
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http://dx.doi.org/10.4103/iju.IJU_174_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6961424PMC
January 2020

Prolonged hormonal therapy and external beam radiation independently increase the risk of Persistent Hypogonadism in men treated with prostate brachytherapy.

Brachytherapy 2020 Mar - Apr;19(2):210-215. Epub 2020 Jan 17.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Purpose: To identify variables that predict persistent hypogonadism and castration in patients with prostate cancer (PCa) treated with brachytherapy (BT).

Materials And Methods: A retrospective analysis was performed on 1,053 patients receiving BT ± external beam radiation therapy (EBRT) ± hormone therapy (HT) for NCCN low, intermediate, or high-risk PCa between 1990 and 2011. Patients were categorized as not receiving HT (n = 438, 41.6%), ≤6 months (n = 317, 31.1%) or > 6 months (n = 298, 28.3%) of HT. 572 (54.3%) received BT alone, and 481 had combination therapy. The five- and 10-year freedom from persistent hypogonadism (T < 280 ng/dL) and castration (T < 50 ng/dL) for each group was evaluated with Kaplan-Meier estimates. Multivariable cox proportional hazards models were used to compare the risk of persistent hypogonadism and castration at a median followup of 6.5 years (posttreatment to final T) (IQR: 4.3-9.1 years; range: 1.0-19.2 years).

Results: The 5-year freedom from hypogonadism rates were 92.4%, 88.9%, and 87.0% for patients with no HT, ≤ 6 months and >6 months of HT, respectively (10-year rates: 66.7%, 55.3%, 40.5%); p < 0.01. The 5-year freedom from castration rates were 99.2%, 98.0%, and 98.4%, respectively (10-year rates: 97.9%, 95.5%, 90.9%); p = 0.078. Number of months of HT (HR = 1.04, p = 0.030) and BT with EBRT vs. BT alone (HR = 1.56, p = 0.010) significantly increased the risk of persistent hypogonadism. Number of months of HT was the only variable which increased the risk of persistent castration (HR = 1.09, p = 0.014).

Conclusions: The addition of EBRT to BT is an independent risk factor for persistent hypogonadism. Prolonged HT additionally increases the risk of persistent hypogonadism and castration.
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http://dx.doi.org/10.1016/j.brachy.2019.12.002DOI Listing
December 2020

A Multi-Institutional Analysis of the Effect of Positive Surgical Margins Following Robot-Assisted Partial Nephrectomy on Oncologic Outcomes.

J Endourol 2020 03 27;34(3):304-311. Epub 2020 Feb 27.

Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

To determine the effect of positive surgical margins (PSMs) on oncologic outcomes following robot-assisted partial nephrectomy (RAPN) and to identify factors that increase the likelihood of adverse oncologic outcomes. A multi-institutional database of patients who underwent RAPN with complete follow-up data was used to compare recurrence-free survival (RFS) and overall survival (OS) between 42 (5.1%) patients with a PSM and 797 (94.9%) patients with a negative surgical margin. Analysis was performed with univariable and multivariable Cox proportional hazard regression models adjusting for confounding variables. A Kaplan-Meier method was used to evaluate the relationship between PSM and oncologic outcomes (RFS and OS), and the equality of the curves was assessed using a log-rank test. The rate of PSM was 5.1%. RFS at 12, 24, and 36 months was 97.8%, 95.2%, and 92.9%. OS at 12, 24, and 36 months was 98.6%, 97.7%, and 93.3%. PSM was not associated with worse RFS in both univariable and multivariable analyses (hazard ratio [HR] = 1.43; 95% confidence interval [CI] = 0.37, 5.55;  = 0.607). Factors associated with worse RFS include pT3a upstaging (HR = 4.97; 95% CI = 1.63, 15.12;  = 0.005), a higher Charlson comorbidity index (HR = 1.68; 95% CI = 1.20, 2.34;  = 0.002); and advanced clinical stage (cT1a cT1b, HR = 4.22; 95% CI = 1.84, 9.68;  = 0.001 cT2a, HR = 14.09; 95% CI = 3.85, 51.53;  < 0.001). PSM was not associated with worse OS in both univariable and multivariable analyses (HR = 0.87; 95% CI = 0.26, 2.94;  = 0.821). Higher R.E.N.A.L. nephrometry score was found to be associated with worse OS (HR = 1.26; 95% CI = 1.01, 1.57;  = 0.041). Given the absence of association between PSM and worse oncologic outcomes, patients with PSM following RAPN should be carefully monitored for recurrence rather than undergo immediate secondary intervention. As advanced clinical stage (cT1b, cT2a) and pathologic upstaging (pT3a) were independently associated with disease recurrence, their presence may warrant more attentive postoperative surveillance.
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http://dx.doi.org/10.1089/end.2019.0506DOI Listing
March 2020

Do patients with Stage 3-5 chronic kidney disease benefit from ischaemia-sparing techniques during partial nephrectomy?

BJU Int 2020 03 26;125(3):442-448. Epub 2019 Dec 26.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Objective: To analyse whether selective arterial clamping (SAC) and off-clamp (OC) techniques during robot-assisted partial nephrectomy (RPN) are associated with a renal functional benefit in patients with Stage 3-5 chronic kidney disease (CKD).

Patients And Methods: The change in estimated glomerular filtration rate (eGFR) over time was compared between 462 patients with baseline CKD 3-5 that underwent RPN with main arterial clamping (MAC) (n = 375, 81.2%), SAC (n = 48, 10.4%) or OC (n = 39, 8.4%) using a multivariable linear mixed-effects model. All follow-up eGFRs, including baseline and follow-up between 3 and 24 months, were included in the model for analysis. The median follow-up was 12.0 months (interquartile range 6.7-16.5; range 3.0-24.0 months).

Results: In the multivariable linear mixed-effects model adjusting for characteristics including tumour size and the R.E.N.A.L. (Radius; Exophytic/Endophytic; Nearness; Anterior/Posterior; Location) Nephrometry Score, the change in eGFR over time was not significantly different between SAC and MAC RPN (β = -1.20, 95% confidence interval [CI] -5.45, 3.06; P = 0.582) and OC and MAC RPN (β = -1.57, 95% CI -5.21, 2.08; P = 0.400). Only 20 (15 MAC, two SAC, three OC) patients overall had progression of their CKD stage at last follow-up. The mean ischaemia time was 17 min for MAC and 15 min for SAC. There was no benefit to SAC or OC in terms of blood loss, perioperative complications, length of stay, or surgical margins.

Conclusion: SAC and OC techniques during RPN were not associated with benefit in preservation of eGFR in patients with baseline CKD.
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http://dx.doi.org/10.1111/bju.14956DOI Listing
March 2020

A multi-institutional analysis of 263 hilar tumors during robot-assisted partial nephrectomy.

J Robot Surg 2020 Aug 26;14(4):585-591. Epub 2019 Sep 26.

Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1272, New York, NY, 10029-5674, USA.

Hilar tumors pose unique challenges during partial nephrectomy. We present the characteristics and outcomes of 263 patients with hilar tumors undergoing robot-assisted partial nephrectomy (RPN) in the largest series to date. Perioperative, pathologic, functional, and oncological outcomes were compared between 1467 (84.8%) patients with a non-hilar tumor and 263 (15.2%) patients with a hilar tumor undergoing RPN. Variables were compared in univariable (unadjusted) analysis and using multivariable linear, logistic, poisson, cox proportional hazards and linear mixed effects regression models adjusting for tumor diameter and RENAL Nephrometry score. Hilar tumors were larger (3.7 vs. 3.0 cm, p < 0.001) and more complex (RENAL Score 9 vs. 7, p < 0.001), leading to longer operative time (186 vs. 161 min, p < 0.001), ischemia time (18 vs. 15, p < 0.001), greater blood loss (150 vs. 100 ml, p < 0.001), eGFR decline at discharge (∆ = 3.9%, p = 0.035) and eGFR decline per month up to 36 months post-RPN (β = - 0.25; p = 0.017). In multivariable analysis, hilar tumors were only associated with a 10% increase in operative time (p ≤ 0.001) and marginally worse eGFR decline over time (β = - 0.19, p = 0.076), with no differences in other outcomes analyzed including ischemia time, blood loss, complication rate, recurrence-free survival, or eGFR decline at discharge. Although hilar tumors were found to be larger and more anatomically complex, there were only marginal differences in outcome when compared to non-hilar tumors. A hilar renal tumor should be considered for partial nephrectomy when feasible without an expected increase in complications or adverse events.
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http://dx.doi.org/10.1007/s11701-019-01028-8DOI Listing
August 2020

Effect of 3-Dimensional Virtual Reality Models for Surgical Planning of Robotic-Assisted Partial Nephrectomy on Surgical Outcomes: A Randomized Clinical Trial.

JAMA Netw Open 2019 09 4;2(9):e1911598. Epub 2019 Sep 4.

Swedish Urology Group, Seattle, Washington.

Importance: Planning complex operations such as robotic-assisted partial nephrectomy requires surgeons to review 2-dimensional computed tomography or magnetic resonance images to understand 3-dimensional (3-D), patient-specific anatomy.

Objective: To determine surgical outcomes for robotic-assisted partial nephrectomy when surgeons reviewed 3-D virtual reality (VR) models during operative planning.

Design, Setting, And Participants: A single-blind randomized clinical trial was performed. Ninety-two patients undergoing robotic-assisted partial nephrectomy performed by 1 of 11 surgeons at 6 large teaching hospitals were prospectively enrolled and randomized. Enrollment and data collection occurred from October 2017 through December 2018, and data analysis was performed from December 2018 through March 2019.

Interventions: Patients were assigned to either a control group undergoing usual preoperative planning with computed tomography and/or magnetic resonance imaging only or an intervention group where imaging was supplemented with a 3-D VR model. This model was viewed on the surgeon's smartphone in regular 3-D format and in VR using a VR headset.

Main Outcomes And Measures: The primary outcome measure was operative time. It was hypothesized that the operations performed using the 3-D VR models would have shorter operative time than those performed without the models. Secondary outcomes included clamp time, estimated blood loss, and length of hospital stay.

Results: Ninety-two patients (58 men [63%]) with a mean (SD) age of 60.9 (11.6) years were analyzed. The analysis included 48 patients randomized to the control group and 44 randomized to the intervention group. When controlling for case complexity and other covariates, patients whose surgical planning involved 3-D VR models showed differences in operative time (odds ratio [OR], 1.00; 95% CI, 0.37-2.70; estimated OR, 2.47), estimated blood loss (OR, 1.98; 95% CI, 1.04-3.78; estimated OR, 4.56), clamp time (OR, 1.60; 95% CI, 0.79-3.23; estimated OR, 11.22), and length of hospital stay (OR, 2.86; 95% CI, 1.59-5.14; estimated OR, 5.43). Estimated ORs were calculated using the parameter estimates from the generalized estimating equation model. Referent group values for each covariate and the corresponding nephrometry score were summed across the covariates and nephrometry score, and the sum was exponentiated to obtain the OR. A mean of the estimated OR weighted by sample size for each nephrometry score strata was then calculated.

Conclusions And Relevance: This large, randomized clinical trial demonstrated that patients whose surgical planning involved 3-D VR models had reduced operative time, estimated blood loss, clamp time, and length of hospital stay.

Trial Registration: ClinicalTrials.gov identifiers (1 registration per site): NCT03334344, NCT03421418, NCT03534206, NCT03542565, NCT03556943, and NCT03666104.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.11598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6751754PMC
September 2019

A Single Overnight Stay After Robotic Partial Nephrectomy Does Not Increase Complications.

J Endourol 2019 12 9;33(12):1003-1008. Epub 2019 Oct 9.

OhioHealth Robotic Urologic and Cancer Surgery, Dublin Methodist Hospital, Dublin, Ohio.

To evaluate the feasibility of postoperative day 1 (POD1) discharge after robotic partial nephrectomy (RPN) and to determine whether a protocol targeting a shorter length of stay (LOS) is associated with any difference in the rate of postoperative complications. We reviewed a prospectively maintained, multi-institutional database of patients who underwent RPN from September 2013 to September 2016. Three of the six participating surgeons used a protocol that targeted discharge on POD1, whereas three surgeons did not. Patient characteristics and postoperative complication rates between the two groups were compared. A total of 665 patients were included, 455 of whom were treated by surgeons utilizing a POD1 discharge protocol, whereas 210 were not. The mean LOS for those in the POD1 protocol group was 1.13 days 2.02 days in the non-protocol group. Between groups, there were no differences in age ( = 0.098), body mass index ( = 0.164), tumor size ( = 0.502), or R.E.N.A.L. Nephrometry score ( = 0.974), but POD1 discharge protocol patients had higher age-adjusted Charlson comorbidity score (4 2,  = 0.033), were less likely to have a hilar tumor (15.9% 23.1%,  = 0.03), and had a larger percent decrease in discharge estimated glomerular filtration rate (-15.9% -7.1%,  < 0.001). There were no differences in the rates of overall ( = 0.715), major ( = 0.164), medical ( = 0.089), or surgical complications ( = 0.301) or in complications by the Clavien-Dindo category ( = 0.13). Discharge on POD1 after RPN is feasible, reproducible by different surgeons, and not associated with an increased risk of postoperative complications.
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http://dx.doi.org/10.1089/end.2019.0218DOI Listing
December 2019

Defining Risk Categories for a Significant Decline in Estimated Glomerular Filtration Rate After Robotic Partial Nephrectomy: Implications for Patient Follow-up.

Eur Urol Oncol 2021 Jun 30;4(3):498-501. Epub 2019 Jul 30.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Following partial nephrectomy (PN), it is important to prevent any deterioration in estimated glomerular filtration rate (eGFR). At present there are no evidence-based recommendations on when a nephrology consultation should be requested and how to adjust postoperative management when the risk of renal function decline is high. In an effort to address this void, we used our previously published nomogram to define risk groups for a significant decline in eGFR at 3-15 mo after PN. We used the nomogram-derived probability as the independent variable for the classification and regression tree and identified four risk groups: low (0-10%), intermediate (10-21%), high (21-65%), and very high (65-100%). Overall, 336 (34%), 386 (39%), 243 (24%), and 34 (4%) patients fell in the low, intermediate, high, and very high risk groups, respectively. The rates of significant eGFR decline across the low, intermediate, high, and very high risk groups were 4%, 14%, 29%, and 79%. With the low risk category as a reference, the hazard ratio for eGFR decline was 3.21 (95% confidence interval [CI] 1.83-5.64) for the intermediate, 7.80 (95% CI 4.52-13.48) for the high, and 27.24 (95% CI 13.8-53.8) for the very high risk group (all p<0.001). These prognostic risk categories can be used to design postoperative follow-up schedules. A multidisciplinary approach can be considered for patients at high and very high risk of eGFR decline. PATIENT SUMMARY: We propose a new stratification system to identify individuals at high risk of a decline in renal function after robotic partial nephrectomy.
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http://dx.doi.org/10.1016/j.euo.2019.07.001DOI Listing
June 2021

Clinicopathological and survival analysis of clinically advanced papillary and chromophobe renal cell carcinoma.

Urol Oncol 2019 10 5;37(10):727-734. Epub 2019 Jun 5.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Introduction: Clinically, the papillary (pRCC) and chromophobe (chRCC) histologic subtypes of renal cell carcinoma (RCC) are viewed as more indolent compared to the more-common clear cell histology (ccRCC). However, there remain advanced cases of these purportedly less-aggressive histologies that lead to significant mortality. We therefore sought to evaluate outcomes of advanced pRCC and chRCC compared to ccRCC utilizing the National Cancer Database's registry of RCC patients.

Materials And Methods: A total of 115,365 ccRCC patients, 28,344 pRCC patients, and 11,942 chRCC patients met eligibility criteria. Overall survival (OS) was estimated using the Kaplan-Meier method (median follow-up 3.6 years). OS was compared between stage III and IV ccRCC, pRCC, and chRCC using multivariable Cox proportional hazards model adjusted for clinical and treatment characteristics.

Results: A total of 25.7% of ccRCC patients, 14.1% of pRCC patients, and 14.8% of chRCC patients had stage III to IV disease. The 5-year OS for stage III ccRCC, pRCC, and chRCC was 66.9%, 63.6%, and 80.5%, respectively. The 5-year OS for stage IV ccRCC, pRCC and chRCC was 19.7%, 13.3%, and 22.0%, respectively. The hazard of death was significantly higher for stage IV pRCC vs. ccRCC (hazard ratio = 1.29; 95% confidence interval = 1.19, 1.39; P < 0.01) and similar for stage IV chRCC vs. ccRCC (hazard ratio = 1.01; 95% confidence interval = 0.85, 1.21; P = 0.885).

Conclusions: pRCC and chRCC are rare but similarly fatal compared to ccRCC when advanced or metastatic. With most clinical trials devoted toward ccRCC, greater efforts to identify aggressive variants and treatment strategies for metastatic pRCC and chRCC are necessary.
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http://dx.doi.org/10.1016/j.urolonc.2019.05.008DOI Listing
October 2019

Trends and outcomes in contemporary management renal cell carcinoma and vena cava thrombus.

Urol Oncol 2019 09 5;37(9):576.e17-576.e23. Epub 2019 Jun 5.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Introduction: We sought to analyze the safety, efficacy, and national trends in the use of robotic radical nephrectomy (RN) and inferior vena cava thrombectomy in patients with renal cell carcinoma.

Patients And Methods: We analyzed 872 patients from the National Cancer Database dataset who underwent open (n = 838, 96.1%) or robotic (n = 34, 3.9%) radical nephrectomy with inferior vena cava thrombectomy for cT3b renal cell carcinoma between 2010 and 2014. Length of stay (LOS), 30-day readmissions and 30-day mortality were compared between the 2 groups. As internal validation, we performed a multi-institutional analysis of 20 patients (9 open [45%] vs. 11 robotic [55%]) undergoing RN with a level II thrombus. Patients were compared in terms of baseline characteristics, peri- and postoperative outcomes. Uni- and multivariable models were used adjusting for clinical and tumor characteristics.

Results: Baseline characteristics were similar between the 2 groups in both datasets. In the National Cancer Database, robotic approach was associated with 26% reduction in LOS (P < 0.001) but no difference in readmissions (odds ratio [OR] = 0.91; 95% confidence interval [CI] = 0.05, 4.50; P = 0.925) or 30-day mortality (OR = 2.72; 95% CI = 0.40, 10.86; P = 0.211). In multicenter database, open group had significantly greater blood loss (600 vs. 100.0 mL, P = 0.020). The rate of blood transfusion was higher in the open group, but was not significant (44.4% vs. 18.2%, P = 0.336). Robotic group had a shorter LOS (1 vs. 5 days; P = 0.026). No difference was seen between the open and robotic groups in terms of operative time (226 vs. 260 minutes, P = 0.922) and postoperative complications (P > 0.999).

Conclusion: In select cases and experienced hands, robotic approach offers a reasonable alternative to open surgery without an increased complication rate.
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http://dx.doi.org/10.1016/j.urolonc.2019.05.010DOI Listing
September 2019

Identifying tumor-related risk factors for simultaneous adrenalectomy in patients with cT1-cT2 kidney cancer during robotic assisted laparoscopic radical nephrectomy.

Minerva Urol Nephrol 2021 Feb 4;73(1):72-77. Epub 2019 Jun 4.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Background: In some cases, preservation of adrenal gland could be at risk in patients with cT1 and cT2 RCC. The aim of this study was to evaluate tumor-related factors that can potentially increase the risk of simultaneous adrenalectomy during robotic-assisted laparoscopic radical nephrectomy (RALRN) in patients with cT1-cT2 disease and the impact of performing such procedure on recurrence-free survival (RFS) and complication rates.

Methods: We used a multi-institutional kidney cancer database where we identified patients who underwent RALRN with or without adrenalectomy. We evaluated the tumor-related characteristics that could potentially increase the risk of adrenal gland resection of these patients. We also reported RFS at 12-24 months of follow-up, which was compared with an inverse probability of treatment weighted (IPTW) multivariable cox proportional hazards regression model and postoperative complications, which was compared with an IPTW multivariable logistic regression model.

Results: Tumor size, cT stage, pT stage, histologic subtype, sarcomatoid differentiation, BMI, lymph node involvement, metastatic disease, Fuhrman grade do not increase the risk of simultaneous adrenalectomy during RALRN. Moreover, RALRN with adrenalectomy had no significant benefit in RFS. No differences in post-operative complications were noted.

Conclusions: Our evaluated tumor-related characteristics did not show to impact the incidence of simultaneous adrenalectomy. Adrenal gland resection T does not provide significant benefit in recurrence-free survival. We consider that RALRN with adrenalectomy should be reserved only for patients with adrenal compromise as stated previously regardless that it has shown to be a safe procedure.
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http://dx.doi.org/10.23736/S0393-2249.19.03440-4DOI Listing
February 2021

Renal cell carcinoma: the oncological outcome is not the only endpoint.

Transl Androl Urol 2019 Mar;8(Suppl 1):S93-S95

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

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http://dx.doi.org/10.21037/tau.2019.01.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511688PMC
March 2019
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