AUA 2018: Comparative Analysis of Minimally Invasive Radical and Partial Nephrectomy for Clinical T2 Renal Mass: Analysis of the Robotic Surgery for Large Renal Mass (ROSULA) Group

San Francisco, CA USA (UroToday.com) Over the last two decades, nephron-sparing surgery has continued to evolve as being standard of care for cT1a patients, as well as increasingly for patients with cT1b tumors, when feasible and in patients with solitary kidneys. With this advancement, feasibility of a partial nephrectomy for cT2 renal masses has been postulated. Given that the da Vinci platform for robotic surgery has allowed highly skilled robotic surgeons to perform many complex procedures minimally invasively, cT2 partial nephrectomy may be feasible. At today’s localized kidney cancer session at AUA 2018, Dr. Bindayi presented results of the ROSULA cooperative group’s outcomes of minimally invasive radical vs partial nephrectomy for cT2 renal masses.

For this study, the authors retrospectively assessed an international multicenter database of minimally invasive partial and radical nephrectomy for cT2 renal masses (T2N0M0) [RObotic Surgery for LArge renal mass (ROSULA) Group]. The primary outcome was change in estimated glomerular filtration rate (δeGFR), and secondary outcomes included complication rates, de novo CKD (eGFR<60 mL/min/1.73m2) and eGFR<45, overall survival (OS) and progression free survival (PFS). The authors utilized multivariable analysis and Kaplan-Meier analysis to assess survival outcomes and predictors of de novo eGFR<45.

There were 847 patients (201 partial nephrectomy and 633 radical nephrectomy) undergoing minimally invasive surgery included in the analysis. The median follow-up was 20 months. Patients undergoing radical nephrectomy had larger tumor size (9.2 vs. 8.5 cm, p<0.001) and RENAL nephrometry score (9.5 vs. 9, p=0.001). Median ischemia time for partial nephrectomies was 22 minutes. There were no significant differences between the two groups for 30 day complications (partial nephrectomy 24% vs. radical nephrectomy 17.9%, p=0.10) or for readmissions (p=0.10). Patients undergoing a partial nephrectomy had higher estimated blood loss (230 mL vs. 174 mL, p=0.03) and positive margin rate (7.8% vs. RN 3.6%, p=0.02), whereas patients undergoing partial nephrectomy had lower δeGFR (9 vs 30, p<0.001), de novo CKD (14.7% vs. 55.6%, p<0.001), and de novo eGFR <45 (4.1% vs. 32.3%, p<0.001). On multivariable analysis, increasing ASA score (HR 5.83, 95%CI 2.17-15.68) was predictive for all-cause mortality, but type of surgery was not (p=0.29). Increasing age (HR 1.07, 95%CI 1.04-1.10) and radical nephrectomy (HR 13.5, 95%CI 5.2-34.9) were independent predictors for de novo eGFR<45. Kaplan-Meier analysis demonstrated an 87% and 82% 5-year OS for patients who underwent partial nephrectomy and radical nephrectomy, respectively (p =0.189), however patients undergoing radical nephrectomy had worse PFS:

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The strength of this study is the multicenter experience and collaborative allowing for a good sample size of patients undergoing partial or radical nephrectomy for patients with cT2 renal masses. Limitations of this study are the inherent selection bias when retrospectively analyzing one procedure vs another procedure. Additionally, the confidence limits for their multivariable models are wide, bringing into question potential overfitting of these models. Dr. Bindayi concluded by suggesting that minimally invasive partial nephrectomy for select patients with cT2 renal masses provides renal functional benefit while not compromising oncologic and outcomes, with seemingly similar morbidity.

Presented by: Ahmet Bindayi, UC San Diego Health System La Jolla, CA

Co-Authors: Zachary Hamilton, Stephen Ryan, La Jolla, CA, Giuseppe Simone, Michele Gallucci, Rome, Italy, Madhumitha Reddy, La Jolla, CA, Gabriele Tuderti, Rome, Italy, Kendrick Yim, La Jolla, CA, Manuela Costantini, Rome, Italy, Andrea Minervini, Andrea Mari, Marco Carini, Florence, Italy, Daniel Eun, Philadelphia, PA, Koon Rha, Seoul, Korea, Republic of, Bo Yang, Shanghai, China, People's Republic of, Francesco Montorsi, Milan, Italy, Alexandre Mottrie, Aalst, Belgium, Alessandro Larcher, Umberto Capitanio, Milan, Italy, Aryeh Keehn, Philadelphia, PA, Francesco Porpiglia, Ricacardo Bertolo, Turin, Italy, Robert Uzzo, Philadelphia, PA, Sisto Perdona, Giuseppe Quarto, Naples, Italy, James Porter, Michael Liao, Seattle, WA, Matteo Ferro, Ottavio De Cobelli, Milan, Italy, Geert De Naeyer, Aalst, Belgium, Kidon Chang, Seoul, Korea, Republic of, Alexander Kutikov, David Chen, Marc Smaldone, Philadelphia, PA, Luigi Schips, Francesco Berardinelli, Chieti, Italy, Wesley White, Knoxville, TN, Chao Zang, Shanghai, China, People's Republic of, Ken Jacobsohn, Peter Langenstroer, Peter Dietrich, Milwaukee, WI, Prokar Dasgupta, Nicole de Luyk, Ben Challacombe, London, United Kingdom, Uzoma Anele, Lance Hampton, Richmond, VA, Clayton Lau, Patrick Kilday, Duarte, CA, Chandru Sundaram, Jay Sulek, Bloomington, IN, Riccardo Autorino, Richmond, VA, Ithaar Derweesh, La Jolla, CA

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, Twitter: @zklaassen_md, at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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