Is Partial Nephrectomy Safe and Effective in the Setting of Frail Comorbid Patients Affected by Renal Cell Carcinoma? Insights from the RECORD 2 Multicentre Prospective Study - Beyond the Abstract

Life expectancy (LE) for patients presenting with newly diagnosed renal cell carcinoma (RCC) is often lower compared to the normal population irrespective of RCC. This observation has prompted the diffusion of active surveillance as a reasonable option in cases with limited LE and features of non-aggressive disease to reduce overtreatment. On the other hand, radical treatment should be avoided in a frail population, because radical nephrectomy (RN) is an independent predictor of cardiovascular events, of renal insufficiency leading to end-stage renal disease and of other comorbidities, which will further shorten LE (10 to 30% of patients die within the first year of dialysis).

In this study, relying on the RECORD 2 project – a multicenter prospective registry of kidney surgery in Italy – we evaluated the perioperative and morbidity outcomes after partial nephrectomy (PN) in patients with short LE (≥95% ten-year expected mortality (10y-EM), we assessed the main predictors of outcomes in this population and to compare these results with those of a group at the extremely opposite upper range of estimated LE (≤5% 10-year expected mortality [10-y EM]).

Ten-year expected mortality was assessed using the age-adjusted CCI score and was used as a surrogate of frailty and comorbidity. 

Overall, 559 patients with short LE (SLE) were selected. Surgical and medical postoperative complication rates were registered in 14.8% and 6% cases. Postoperative acute kidney injury (AKI) was reported in 27.3% cases, positive surgical margins (PSM) in 9.3% cases.

Several multivariable analyses for perioperative outcomes have been performed in the SLE population:
  • ASA score (odds ratio [OR] 2.24, p<0.001), history of previous cerebrovascular disease (OR 2.6, p=0.007), surgery being performed in a low-volume center (OR 1.76, p=0.03) and with an open compared to a robotic approach were independent predictors for experiencing postoperative complications.
  • ASA (OR 1.75, and PADUA (OR 1.15, p=0.03) score, hilar clamping (OR 1.75, p=0.02) and standard PN compared to simple enucleation (OR 1.57, p=0.01) were associated with an increased risk of postoperative AKI whilst higher pre-operative eGFR (OR 0.98, p<0.001) was found to be a protective factor.
  • History of myocardial infarction (OR 2.46, p<0.001), hilar clamping (OR 1.75, p=0.02), and enucleation vs. standard PN technique (OR 1.27, p=0.03) were independently associated with an increased likelihood of experiencing eGFR decrease >25% at two years.
  • PADUA score (OR 1.21, p=0.01), renal sinus involvement (OR 1.67, p=0.09), open compared to a laparoscopic approach (OR 1.29, p=0.01), and enucleation vs. standard PN technique (OR 3.63, p<0.001) were independent predictors of positive surgical margins.

Patients with SLE were compared with those with long LE (LLE) (n=302). 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% vs. 9.9%, p<0.0001), while the overall intraoperative complications (4.1% vs. 2.3%), overall postoperative major complications (3.8% vs. 1.9%) adjusted AKI (24.2% vs. 22.6%), positive surgical margins (8% vs. 6.4%) and 2-year RF loss (13.4% vs 12.4%).

In conclusion, PN is feasible in patients with SLE with an acceptable safety profile that is comparable to patients with no life expectancy limitations.

Written by: Andrea Mari, MD, Consultant of Urology, Twitter: @andreamari08, Andrea Minervini, MD, Associate Professor of Urology, Twitter: @minerviniandre, Paolo Gontero, MD, Professor of Urology, Chairman Department of Urology, Twitter: @paolo_gontero, Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy

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