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990 PARTIAL NEPHRECTOMY VERSUS RADIAL NEPHRECTOMY FOR T1B RENAL CELL CARCINOMA: ONCOLOGICAL AND FUNCTIONAL OUTCOMES
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
groups respectively. Mean patient age, creatinine, and overall operative time were not significantly different. Major/minor complication rates for all three groups were 12%/10% (OPN), 4%/6% (LPN), and 2%/2% (RPN). Mean tumor size for the OPN, LPN, and RPN groups was 2.5 cm, 2.0 cm, and 2.8 cm respectively. Pathology demonstrated renal cell carcinoma in 92%, 70%, and 82% while microscopic positive margins on final pathology were seen in 2%, 12%, and 4% of the OPN, LPN, and RPN specimens respectively. Median follow up for OPN, LPN, and RPN were 21 months, 40 months, and 12 months respectively. There were no cancer recurrences in the LPN and RPN groups, but 2 patients with local recurrence in the OPN arm were detected with one patient undergoing cryotherapy after recurrence was diagnosed. CONCLUSIONS: LPN and RPN have several similar operative characteristics and outcomes compared to OPN. However, in the hands of experienced laparoscopic and robotic surgeons, LPN and RPN appear to be associated with decreased length of stay and estimated blood loss. Although the robotic approach to NSS may be technically challenging, equivalent, if not improved, perioperative complication rates and oncologic outcomes are demonstrated when compared to OPN and LPN. Larger comparative studies with longer follow up and standardized reporting of tumor difficulty are needed to further evaluate the optimal role for each approach to NSS. Source of Funding: Work supported by the Fox Chase Cancer Center Keystone Program in Personalized Kidney Cancer Therapy.
989 PREDICTORS OF WORSENING GFR FOLLOWING PARTIAL NEPHRECTOMY: IS BEING OFF-CLAMP THE FINAL STRATEGY? Arun Srinivasan*, Amin Herati, Arvin George, Soroush Rais-Bahrami, Louis Kavoussi, New Hyde Park, NY INTRODUCTION AND OBJECTIVES: Recent focus in laparoscopic nephron sparing surgery has been to identify techniques to decrease warm ischemia time and thus scale down renal insult. We endeavored to identify the preoperative and intraoperative factors that best predict renal injury. Identifying these factors would lend themselves for innovation and eventually decrease renal injury. METHODS: We retrospectively evaluated patients who underwent laparoscopic partial nephrectomy. We utilized univariate analysis by general linear model to identify preoperative and intraoperative variables that best correlate with renal insult evidenced by post operative deterioration in glomerular filtration rate. A regression analysis was then performed to identify the best predictor of this injury controlling for their inter-relationship.All preoperative and intra-operative factors were included in the prediction model including history of diabetes or hypertension, preoperative creatinine, ASA class, estimated blood loss, on-clamp surgery or off-clamp surgery, clamp time, location of tumors, size of tumors, hilar position or not, age at surgery and BMI. RESULTS: We retrospectively studied 273 patients who underwent laparoscopic partial nephrectomy between June 2006 and July 2009 by a single surgeon. 32% of these patients had off-clamp partial nephrectomy. By univariate analysis, significant predictors of renal insult were age at surgery, hilar location of tumors, clamp time, offclamp partial nephrectomy and duration of surgery. Off-clamp surgery and clamp time as variables are mutually exclusive. Hence we constructed our regression models with either clamp time or off clamp surgery. By multivariate regression analysis, clamp time(p⫽0.015) and off-clamp surgery(p⫽0.02) emerged as the only significant predictors of renal injury. CONCLUSIONS: The best predictor of renal injury after laparoscopic partial nephrectomy is shorter clamp time during on-clamp partial nephrectomy or performing laparoscopic partial nephrectomy off-clamp. We find that performing off-clamp laparoscopic partial nephrectomy might be the ultimate strategy to protect renal function. Source of Funding: None
THE JOURNAL OF UROLOGY姞
e385
990 PARTIAL NEPHRECTOMY VERSUS RADIAL NEPHRECTOMY FOR T1B RENAL CELL CARCINOMA: ONCOLOGICAL AND FUNCTIONAL OUTCOMES Sangjun Yoo*, Taejin Kang, Cheryn Song, Jun Hyuk Hong, Choung-Soo Kim, Hanjong Ahn, SEOUL, Korea, Republic of INTRODUCTION AND OBJECTIVES: To compare the oncological and functional outcomes of radical nephrectomy (RN) and partial nephrectomy (PN) for T1b renal cell carcinoma. METHODS: We identified 27 patients who underwent PN for T1b renal cell carcinoma at Asan Medical Center between Jan 1991 and Dec 2007. Each case was matched with 2 patients with identical demographic, clinical and pathological characteristics who underwent RN during the same period. Recurrence-free and cancer specific survival, glomerular filtration rate (GFR) calculated by modification of diet in renal disease equation and chronic kidney disease (CKD) status were compared between the PN and RN group. All cases were done electively and there were no patients with single kidney in both groups. RESULTS: Mean tumor size was 5 cm in both groups but extra-renal tumor diameter/total tumor diameter ratio was higher in the PN group (PN, 56.7%; RN, 38.1%, p⫽0.001). PN group had longer renal sinus-tumor length than RN group (PN, 0.54cm; RN, 0.22cm, p⫽0.017). In RN group, one local recurrence was observed and no cancer-specific death occurred during a mean follow up of 45 months. In PN group, there was no local recurrence or cancer-specific death during a mean follow up of 48 months demonstrating equivalent oncological outcome to RN group. Number of patients with hypertension or diabetes preoperatively was 7 and 11 in PN and RN groups, respectively. Incidence of CKD was 1 in both groups (3.7% and 1.9%). Pre-operative GFR of PN group was 88.4ml/min/1.73min2 and of RN group was 93.0ml/min/1.73min2 (p⫽0.298). At postoperative 1 year, 2 years, and 3 years GFR changed to 82.8ml/min/1.73min2, 80.6ml/min/ 1.73min2, and 80.9ml/min/1.73min2 in PN group and 62.3ml/min/ 1.73min2, 64.2ml/min/1.73min2, 66.6ml/min/1.73min2 in RN group (PN vs. RN; preop. vs. postop., all p⬍0.05). Postoperative CKD developed in 1 patient in PN group (3.8%, 1/26) whereas 18(34.0%, 18/53) patients demonstrated CKD in the RN group. CONCLUSIONS: In T1b renal cell carcinoma, PN exhibited comparable oncological outcome and superior renal function preservation compared to RN. In technically amenable cases, PN can be safely considered as a primary option. Source of Funding: None
991 ASSESSMENT OF RENAL DAMAGE FOLLOWING WARM ISCHEMIA TIME DURING LPN: RESULTS OF A PROSPECTIVE STUDY Francesco Porpiglia*, Cristian Fiori, Ivano Morra, Riccardo Bertolo, Patrizia Angusti, Valerio Podio, Roberto Mario Scarpa, Orbassano (Torino), Italy INTRODUCTION AND OBJECTIVES: The aim of this prospective study is to evaluate the renal damage and the impairment of renal function due to warm ischemia time after laparoscopic partial nephrectomy (LPN). METHODS: fter Institutional approval, 57 patients were involved in the study which lasted from October 2006 to December 2008. Patients underwent LPN for renal tumour with transperitoneal or retroperitoneal approach, in all cases tumour resection and parenchymal reconstruction were performed after the clamp of renal artery. Patients were divided into three Groups according to WIT: Group A ⬍ 20 min; group B ⬎ 20 and ⬍ 30 min; Group C ⬎ 30 min. Daily proteinuria, serum creatinine (CrS), and creatinine clearance (CrCl) were assessed preoperatively, at 5th postoperative day and at 3rd month. Renal scintigraphy was performed before the procedure, at 5th day, at 3rd month and at one year postoperatively to evaluate the percentage of contribution to renal function (%RF) by the injured kidney and to
groups respectively. Mean patient age, creatinine, and overall operative time were not significantly different. Major/minor complication rates for all three groups were 12%/10% (OPN), 4%/6% (LPN), and 2%/2% (RPN). Mean tumor size for the OPN, LPN, and RPN groups was 2.5 cm, 2.0 cm, and 2.8 cm respectively. Pathology demonstrated renal cell carcinoma in 92%, 70%, and 82% while microscopic positive margins on final pathology were seen in 2%, 12%, and 4% of the OPN, LPN, and RPN specimens respectively. Median follow up for OPN, LPN, and RPN were 21 months, 40 months, and 12 months respectively. There were no cancer recurrences in the LPN and RPN groups, but 2 patients with local recurrence in the OPN arm were detected with one patient undergoing cryotherapy after recurrence was diagnosed. CONCLUSIONS: LPN and RPN have several similar operative characteristics and outcomes compared to OPN. However, in the hands of experienced laparoscopic and robotic surgeons, LPN and RPN appear to be associated with decreased length of stay and estimated blood loss. Although the robotic approach to NSS may be technically challenging, equivalent, if not improved, perioperative complication rates and oncologic outcomes are demonstrated when compared to OPN and LPN. Larger comparative studies with longer follow up and standardized reporting of tumor difficulty are needed to further evaluate the optimal role for each approach to NSS. Source of Funding: Work supported by the Fox Chase Cancer Center Keystone Program in Personalized Kidney Cancer Therapy.
989 PREDICTORS OF WORSENING GFR FOLLOWING PARTIAL NEPHRECTOMY: IS BEING OFF-CLAMP THE FINAL STRATEGY? Arun Srinivasan*, Amin Herati, Arvin George, Soroush Rais-Bahrami, Louis Kavoussi, New Hyde Park, NY INTRODUCTION AND OBJECTIVES: Recent focus in laparoscopic nephron sparing surgery has been to identify techniques to decrease warm ischemia time and thus scale down renal insult. We endeavored to identify the preoperative and intraoperative factors that best predict renal injury. Identifying these factors would lend themselves for innovation and eventually decrease renal injury. METHODS: We retrospectively evaluated patients who underwent laparoscopic partial nephrectomy. We utilized univariate analysis by general linear model to identify preoperative and intraoperative variables that best correlate with renal insult evidenced by post operative deterioration in glomerular filtration rate. A regression analysis was then performed to identify the best predictor of this injury controlling for their inter-relationship.All preoperative and intra-operative factors were included in the prediction model including history of diabetes or hypertension, preoperative creatinine, ASA class, estimated blood loss, on-clamp surgery or off-clamp surgery, clamp time, location of tumors, size of tumors, hilar position or not, age at surgery and BMI. RESULTS: We retrospectively studied 273 patients who underwent laparoscopic partial nephrectomy between June 2006 and July 2009 by a single surgeon. 32% of these patients had off-clamp partial nephrectomy. By univariate analysis, significant predictors of renal insult were age at surgery, hilar location of tumors, clamp time, offclamp partial nephrectomy and duration of surgery. Off-clamp surgery and clamp time as variables are mutually exclusive. Hence we constructed our regression models with either clamp time or off clamp surgery. By multivariate regression analysis, clamp time(p⫽0.015) and off-clamp surgery(p⫽0.02) emerged as the only significant predictors of renal injury. CONCLUSIONS: The best predictor of renal injury after laparoscopic partial nephrectomy is shorter clamp time during on-clamp partial nephrectomy or performing laparoscopic partial nephrectomy off-clamp. We find that performing off-clamp laparoscopic partial nephrectomy might be the ultimate strategy to protect renal function. Source of Funding: None
THE JOURNAL OF UROLOGY姞
e385
990 PARTIAL NEPHRECTOMY VERSUS RADIAL NEPHRECTOMY FOR T1B RENAL CELL CARCINOMA: ONCOLOGICAL AND FUNCTIONAL OUTCOMES Sangjun Yoo*, Taejin Kang, Cheryn Song, Jun Hyuk Hong, Choung-Soo Kim, Hanjong Ahn, SEOUL, Korea, Republic of INTRODUCTION AND OBJECTIVES: To compare the oncological and functional outcomes of radical nephrectomy (RN) and partial nephrectomy (PN) for T1b renal cell carcinoma. METHODS: We identified 27 patients who underwent PN for T1b renal cell carcinoma at Asan Medical Center between Jan 1991 and Dec 2007. Each case was matched with 2 patients with identical demographic, clinical and pathological characteristics who underwent RN during the same period. Recurrence-free and cancer specific survival, glomerular filtration rate (GFR) calculated by modification of diet in renal disease equation and chronic kidney disease (CKD) status were compared between the PN and RN group. All cases were done electively and there were no patients with single kidney in both groups. RESULTS: Mean tumor size was 5 cm in both groups but extra-renal tumor diameter/total tumor diameter ratio was higher in the PN group (PN, 56.7%; RN, 38.1%, p⫽0.001). PN group had longer renal sinus-tumor length than RN group (PN, 0.54cm; RN, 0.22cm, p⫽0.017). In RN group, one local recurrence was observed and no cancer-specific death occurred during a mean follow up of 45 months. In PN group, there was no local recurrence or cancer-specific death during a mean follow up of 48 months demonstrating equivalent oncological outcome to RN group. Number of patients with hypertension or diabetes preoperatively was 7 and 11 in PN and RN groups, respectively. Incidence of CKD was 1 in both groups (3.7% and 1.9%). Pre-operative GFR of PN group was 88.4ml/min/1.73min2 and of RN group was 93.0ml/min/1.73min2 (p⫽0.298). At postoperative 1 year, 2 years, and 3 years GFR changed to 82.8ml/min/1.73min2, 80.6ml/min/ 1.73min2, and 80.9ml/min/1.73min2 in PN group and 62.3ml/min/ 1.73min2, 64.2ml/min/1.73min2, 66.6ml/min/1.73min2 in RN group (PN vs. RN; preop. vs. postop., all p⬍0.05). Postoperative CKD developed in 1 patient in PN group (3.8%, 1/26) whereas 18(34.0%, 18/53) patients demonstrated CKD in the RN group. CONCLUSIONS: In T1b renal cell carcinoma, PN exhibited comparable oncological outcome and superior renal function preservation compared to RN. In technically amenable cases, PN can be safely considered as a primary option. Source of Funding: None
991 ASSESSMENT OF RENAL DAMAGE FOLLOWING WARM ISCHEMIA TIME DURING LPN: RESULTS OF A PROSPECTIVE STUDY Francesco Porpiglia*, Cristian Fiori, Ivano Morra, Riccardo Bertolo, Patrizia Angusti, Valerio Podio, Roberto Mario Scarpa, Orbassano (Torino), Italy INTRODUCTION AND OBJECTIVES: The aim of this prospective study is to evaluate the renal damage and the impairment of renal function due to warm ischemia time after laparoscopic partial nephrectomy (LPN). METHODS: fter Institutional approval, 57 patients were involved in the study which lasted from October 2006 to December 2008. Patients underwent LPN for renal tumour with transperitoneal or retroperitoneal approach, in all cases tumour resection and parenchymal reconstruction were performed after the clamp of renal artery. Patients were divided into three Groups according to WIT: Group A ⬍ 20 min; group B ⬎ 20 and ⬍ 30 min; Group C ⬎ 30 min. Daily proteinuria, serum creatinine (CrS), and creatinine clearance (CrCl) were assessed preoperatively, at 5th postoperative day and at 3rd month. Renal scintigraphy was performed before the procedure, at 5th day, at 3rd month and at one year postoperatively to evaluate the percentage of contribution to renal function (%RF) by the injured kidney and to