Toward Individualized Approaches to Partial Nephrectomy: Assessing the Correlation Between Ischemia Time and Patient Health Status (RECORD2 Project).

Ischemia time during partial nephrectomy (PN) is among the greatest determinants of acute kidney injury (AKI). Whether this association is affected by the preoperative risk of AKI has never been investigated.

To assess the effect of the interaction between the preoperative risk of AKI and ischemia time on the probability of AKI during PN.

Data of 944 patients treated with on-clamp PN for cT1 renal tumors were extracted from the Registry of Conservative and Radical Surgery for Cortical Renal Tumor Disease (RECORD2) database, a prospective multicenter project.

We estimated the preoperative risk of AKI (defined according to the risk/injury/failure/loss/end-stage [RIFLE] criteria) according to age, baseline renal function, clinical stage, preoperative aspects and dimensions used for an anatomical (PADUA) score, and surgical approach. Classification and regression tree (CART) analysis identified patients at "high" and "low" risk of AKI. Finally, we plotted the probability of AKI over ischemia time stratified by the preoperative risk of AKI.

Overall, 235 (25%) patients experienced AKI after surgery. At multivariable analysis, older patients, those with more complex tumors, those with higher baseline function, and those treated with open surgery had an increased risk of AKI (all p ≤ 0.011). According to the first split at CART analysis, patients were categorized as those with "high" and "low" risk of AKI having a probability of >40% or <40%. For low-risk patients, the probability of AKI in case of <10 versus >20 min of ischemia was 13% versus 28% (absolute risk increase 15%). The risk of AKI for high-risk patients who had <10 versus >20 min of ischemia was 31% versus 77%. This corresponds to an absolute risk increase of 45%. Limitations include retrospective data analyses and lack of surgeons' prior experience.

Ischemia time during PN has different implications for patients with different health status. Clamp time seems less clinically relevant for patients in good conditions who may endure prolonged ischemia with a mild increase in the risk of AKI, whereas frail patients seem to be more vulnerable to ischemic damage even for short clamp time. For individualized intra- and postoperative management, duration of ischemia needs to be questioned in the context of the individual health status.

Functional sequelae related to ischemia time during partial nephrectomy depend on baseline health status. The correlation between the duration of ischemia and baseline health status should be taken into account toward individualized intra- and postoperative management.

European urology oncology. 2020 Jul 06 [Epub ahead of print]

Carlo Andrea Bravi, Andrea Mari, Alessandro Larcher, Daniele Amparore, Alessandro Antonelli, Walter Artibani, Roberto Bertini, Pierluigi Bove, Eugenio Brunocilla, Luigi Da Pozzo, Fabrizio di Maida, Cristian Fiori, Andrea Gallioli, Paolo Gontero, Vincenzo Li Marzi, Nicola Longo, Vincenzo Mirone, Francesco Porpiglia, Bernardo Rocco, Riccardo Schiavina, Luigi Schips, Claudio Simeone, Salvatore Siracusano, Riccardo Tellini, Carlo Terrone, Carlo Trombetta, Vincenzo Ficarra, Marco Carini, Francesco Montorsi, Umberto Capitanio, Andrea Minervini

Division of Oncology/Unit of Urology, URI-Urological Research Institute, Vita-Salute University, IRCCS San Raffaele Hospital, Milan, Italy., Department of Urology, University of Florence, Unit of oncologic minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy., Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, School of Medicine, Orbassano, Turin, Italy., Department of Urology, Ospedali Civili Hospital, University of Brescia, Brescia, Italy., Department of Urology, Azienda Ospedaliera Universitaria Integrata (A.O.U.I.), Verona, Italy., Department of Urology, University Hospital of Tor Vergata, Rome, Italy., Department of Urology, University of Bologna, Bologna, Italy; Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy., Department of Urology, Papa Giovanni XXIII Hospital, Bergamo, Italy., Department of Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy., Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Turin, Turin, Italy., Department of Urology, Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy., Department of Urology, University Federico II, Naples, Italy., Department of Urology, Ospedale Policlinico e Nuovo Ospedale Civile S. Agostino Estense Modena, University of Modena and Reggio Emilia, Modena, Italy., Department of Urology, SS Hospital. Annunziata, Chieti, Italy., Department of Urology, University of Genova, Genova, Italy., U.C.O. Clinica Urologica, Università degli Studi di Trieste, Trieste, Italy., Department of Human and Paediatric Pathology, Gaetano Barresi, Urologic Section, University of Messina, Messina, Italy., Department of Urology, University of Florence, Unit of oncologic minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy. Electronic address: .

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