To investigate the perioperative and morbidity outcomes after partial nephrectomy (PN) in patients with short life expectancy (SLE) (≥95% 10-year expected mortality (10y-EM)), to assess the main predictors of outcomes in this population and to compare these results with those of a group at the opposite upper range with long LE (LLE, ≤5% 10y-EM) relying on a multicenter Italian prospective registry of kidney surgery (the RECORD 2 project).
Clinical data of 4,325 patients undergone kidney surgery were collected at 26 urological Italian Centers from 2013 to 2016. SLE was defined as a ≥95% 10y-EM (assessed using the age-adjusted Charlson comorbidity index [CCI]). A multivariable logistic regression for overall postoperative complications, acute kidney injury (AKI), positive surgical margins (SM) and ∆ estimated glomerular filtration rate (eGFR) ≥25% at 2 years from surgery was performed in patients with SLE including clinically relevant variables. Adjusted outcomes reported as mean (SD) of the 2 groups were generated using separate multivariable logistic regression models and compared.
Overall, 559 patients with SLE were selected. Patients had an ASA score ≥3 in 58.4% of cases. A clinical T1a, T1b, and T2 stage was found in 412 (74.5%), 124 (22.4%), and 17 (3.1%) patients. The median PADUA score was 7 (6-8). Surgical and medical postoperative complication rates were registered in 14.8% and 6% cases. Postoperative AKI was reported in 27.3% cases, positive surgical margins (PSM) in 9.3% cases. In this subgroup of patients, ASA score, cerebrovascular disease, surgery in low volume centers, and open surgery were independent predictors of overall complications. ASA and PADUA scores, renal clamping, resection technique and lower eGFR at baseline were independent predictors of AKI. PADUA score, open approach and resection technique were independent predictors of PSM. Cardiovascular disease, hilar clamping, and resection technique were independent predictors of eGFR decrease >25% at 2 years from surgery. Patients with SLE were compared with those with LLE (n = 302). All analyzed parameters at baseline were significantly different among the groups with the exception of cancer laterality. After adjusting for several clinical variables, the SLE group had a significantly higher risk rate of adjusted overall postoperative complication rate compared to the LLE group (20.6% ± 0.36 vs. 9.9% ± 0.65, P < 0.0001), while the overall intraoperative complications (4.1% ±0.13 vs. 2.3% ± 0.23), overall postoperative major complications (3.8% ± 0.09 vs. 1.9% ± 0.14) adjusted AKI (24.2% ± 0.37 vs. 22.6% ± 0.92), positive surgical margins (8% ± 0.22 vs. 6.4% ± 0.49), and 2-year RF loss (13.4% ± 0.17 vs. 12.4% ± 0.74).
In selected patients with SLE, PN is feasible with an acceptable safety profile that is overall comparable to patients with no LE limitations. While a robotic approach and surgery performed in high volume centers could reduce the risk of complications, an off-clamp approach and a SE surgical technique may decrease the risk of postoperative AKI and of longer term eGFR decrease.
Urologic oncology. 2020 Oct 27 [Epub ahead of print]
Paolo Gontero, Andrea Mari, Giancarlo Marra, Sebastiano Nazzani, Marco Allasia, Alessandro Antonelli, Maurizio Barale, Eugenio Brunocilla, Umberto Capitanio, Fabrizio Di Maida, Andrea Gallioli, Nicola Longo, Francesco Montorsi, Francesco Porpiglia, Angelo Porreca, Bernardo Rocco, Claudio Simeone, Riccardo Schiavina, Riccardo Tellini, Carlo Terrone, Donata Villari, Vincenzo Ficarra, Marco Carini, Andrea Minervini
Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy., Department of Urology, University of Florence, Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy., Department of Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Policlinico, University of Milan, Milan, Italy., Department of Urology, Azienda Ospedaliera Universitaria Integrata (A.O.U.I.), Verona, Italy., Department of Urology, University of Bologna, Bologna, Italy; Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy., Unit of Urology, Division of Experimental Oncology, URI-Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy., Department of Urology, University Federico II of Naples, Naples, Italy., Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, School of Medicine, Orbassano, Turin, Italy., Department of Robotic Urologic Surgery, Abano Terme Hospital, Abano Terme, Italy., Urology Department, University of Modena & Reggio Emilia, Modena, Italy., Department of Urology, Spedali Civili Hospital, University of Brescia, Brescia, Italy., Department of Urology, Policlinico San Martino Hospital, University of Genova, Italy., Department of Urology, University of Florence, Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, Florence, 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: .