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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