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MP84-05 VARIATION IN SURGICAL MARGIN STATUS BY SURGICAL APPROACH AMONG PATIENTS UNDERGOING PARTIAL NEPHRECTOMY FOR SMALL RENAL MASSES
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Tuesday, May 19, 2015
MP84-03 CLINICAL, PATHOLOGICAL AND RENAL FUNCTIONAL OUTCOMES OF PARTIAL AND RADICAL NEPHRECTOMY IN ELDERLY PATIENTS Yajie An, Mark Ball*, Michael Gorin, Phillip Pierorazio, Mohamad Allaf, Baltimore, MD INTRODUCTION AND OBJECTIVES: Partial nephrectomy (PN) is the preferred surgical treatment for most patients with cT1 renal masses, while radical nephrectomy (RN) is reserved for larger tumors, locally advanced tumors, and tumors not amenable to PN. Identifying patients that benefit most from PN is active area of investigation. Because the renal functional benefit of PN is realized over many years and is the procedure is associated with a higher complication rate than RN, elderly patients may not receive the benefit of PN at the cost of higher risk. We sought to characterize perioperative, renal functional and oncologic outcomes of elderly patients undergoing surgery. METHODS: Our institutional renal mass registry was queried for patients > 65 years who underwent PN or RN. Clinicopathologic features and perioperative outcomes were compared between groups. Renal function outcomes as measured by change in GFR and freedom from GFR < 45 were analyzed. Overall survival (OS) and cancer-specific survival (CSS) were compared using the Kaplan-Meier method and Cox proportional hazard regression. RESULTS: Overall, 889 patients met inclusion criteria. Of these 441 (49.6) underwent PN and 448 (50.4) underwent RN. Patients undergoing RN tended to be older (median age 71.9 vs 70.3 years, p < 0.001), had larger tumors (5.5 vs 2.8 cm, p < 0.001), a higher proportion of RCC (89.8% vs 76.6%m p < 0.001) but had similar ASA scores (median score 3 vs 3, p ¼0.1). There were no difference in between RN and PN in terms of operative time (median time 186 vs 195 minutes, p¼0.5), median estimated blood loss (200 vs 200, p ¼ 0.7). Complications rates were similar for RN and PN (overall 51.5% vs 48.5%, p ¼ 0.5 ; Clavien I-II 30.9 vs26.9%, p ¼0.2, Clavien III-IV 8.9% vs 10.8%, p ¼0.2 ). RN was associated with a greater median change in GFR on last follow-up (19.2 vs 7.6, p < 0.001) and freedom from GFR<45 (53.2% vs 24.7%, p<0.001). On multivariable analysis controlling for tumor diameter, pathologic stage and ASA score, PN was associated with improved OS (HR 0.57, 95%CI 0.39-0.82, p < 0.001) and CSS (HR 0.26, 95%CI.09-0.73, p ¼ 0.01). CONCLUSIONS: In this series, PN was associated with similar perioperative outcomes as RN, but with superior. renal functional outcomes. Both OS and CSS favored PN, though selection bias likely exist. These data suggest that elderly patients may benefit from PN and age alone should not be a contraindication to nephron-sparing surgery. Source of Funding: None
MP84-04 GENDER AND RACIAL DISPARITIES IN UTILIZATION OF PARTIAL NEPHRECTOMY FOR RENAL MASSES Shane Pearce*, Zoe Steinberg, Chicago, IL; Richard Zigeuner, Graz, Austria; Chaidir Mochtar, Jakarta, Indonesia; Guillermo Gueglio, Buenos Aires, Argentina; Arieh Shalhav, Scott Eggener, Chicago, IL; M. Pilar Laguna, Amsterdam, Netherlands INTRODUCTION AND OBJECTIVES: Our objective was to assess for gender and racial disparities in the use of partial nephrectomy (PN) in a large, contemporary global population treated for renal masses. METHODS: The Clinical Research Office of the Endourological Society (CROES) Global Renal Mass Study is a prospective database of consecutive patients with renal masses treated during a 1-year period at 98 centers worldwide. Epidemiologic, clinical and pathologic data were compared between genders, limiting analysis to patients undergoing radical nephrectomy (RN) or PN. Multivariable regression analysis was performed to calculate odds of undergoing PN. RESULTS: Subjects (n¼3,625) included 2,332 men (64%) and 1,293 women (36%). PN was performed in 43% and 40% of women and
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men, respectively (p¼0.14). The cohort was 84% Caucasian, 10% Asian, 2% African-American, and 4% Latin-American. Mean age was 61 13 and 68% presented with an incidentally detected mass with no significant differences between men and women (p>0.05). Comparing men to women, there was no difference in tumor size > 4cm (58% vs 58% p¼0.8), tumor location (p¼0.6), percent exophytic (p¼0.7), clinical T stage (p¼0.1) and clinical N stage (p¼0.2). Women were more likely to be pT1 (67% vs 62%, p<0.01) and have benign pathology (17% vs 9% p<0.01). On multivariable analysis, independent predictors of undergoing PN included female gender (OR 1.23 p¼0.05), tumor size < 4cm (OR 10.0 p<0.01), multiple tumors (OR 2.27, p¼0.01) and increasing percent exophytic (25-50%: OR 1.45 p<0.01; 51-75%: OR 2.70 p<0.01; >75%: OR 2.70 p<0.01). Factors associated with reduced odds of PN include African-American race (OR 0.38 p¼0.01), age (OR 0.97 p<0.01), symptomatic mass (0.29 p<0.01), mid-pole location (OR 0.73 p¼0.02), and hilar location (OR 0.28 p<0.01). CONCLUSIONS: This study identified multiple clinical predictors for utilization of partial nephrectomy in a large, contemporary database. Female gender increased odds of undergoing partial nephrectomy, while African-American race independently reduced likelihood of partial nephrectomy. Further research is needed to characterize these disparities and facilitate uniform care delivery. Source of Funding: The Global Renal Mass Study was supported by an unrestricted educational grant from STORZ.
MP84-05 VARIATION IN SURGICAL MARGIN STATUS BY SURGICAL APPROACH AMONG PATIENTS UNDERGOING PARTIAL NEPHRECTOMY FOR SMALL RENAL MASSES Jonathan E. Kiechle, Robert Abouassaly, William Tabayoyong*, Shan Dong, Cleveland, OH; Marc C. Smaldone, Philadelphia, PA; Edward E. Cherullo, Cleveland, OH; Cary P. Gross, New Haven, CT; Nilay D. Shah, Rochester, MN; Hui Zhu, Simon P. Kim, Cleveland, OH INTRODUCTION AND OBJECTIVES: Clinical guidelines recommend partial nephrectomy (PN) for small renal masses (SRM’s) when technically feasible. However, the introduction of laparoscopy and robotic surgery has changed the use of PN. It is unknown whether surgical margins, which can be viewed as a quality indicator, have been affected by the introduction of new surgical approaches. Therefore, we sought to assess the relationship of surgical margin status among patients undergoing PN for SRM from a population-based cohort. METHODS: We used the National Cancer Database to identify all patients who received a PN in 2010 and 2011. The primary outcome was the incidence of positive surgical margins for PN for open and minimally invasive surgical approaches. Multivariable logistic regression analysis was used to identify patient and hospital factors associated with positive surgical margins for PN. RESULTS: Among 15,469 patients who underwent PN, 45% (n¼6,958) had an open PN, 14% (n¼2,163) laparoscopic PN, and 37.6% (n¼5816) robotic PN. The overall prevalence of positive margins was 7.1%. The prevalence of positive margins was 5.5%, 8.1%, and 8.7% for open, laparoscopic, and robotic PN, respectively (p < 0.001). When compared to the open approach, there were higher adjusted odds ratios for positive surgical margins for laparoscopic PN (OR: 1.6; p<0.001) and for robotic PN (OR: 1.6; p<0.001). When stratified by hospital type, differences in positive margin rates remained with minimally invasive techniques such that patients treated at academic medical centers who underwent laparoscopic (OR 1.4; p ¼ 0.02) or robotic (OR 1.6; p <0.001) PN had higher adjusted odds ratios compared to patients treated with open surgery. CONCLUSIONS: Both minimally-invasive approaches for PN are associated with higher rates of positive surgical margins for SRM’s. Follow-up studies will help establish if these differences persist longterm or if they are related to the initial learning curve associated with the introduction of these relatively novel surgical approaches. Source of Funding: None
Vol. 193, No. 4S, Supplement, Tuesday, May 19, 2015
MP84-03 CLINICAL, PATHOLOGICAL AND RENAL FUNCTIONAL OUTCOMES OF PARTIAL AND RADICAL NEPHRECTOMY IN ELDERLY PATIENTS Yajie An, Mark Ball*, Michael Gorin, Phillip Pierorazio, Mohamad Allaf, Baltimore, MD INTRODUCTION AND OBJECTIVES: Partial nephrectomy (PN) is the preferred surgical treatment for most patients with cT1 renal masses, while radical nephrectomy (RN) is reserved for larger tumors, locally advanced tumors, and tumors not amenable to PN. Identifying patients that benefit most from PN is active area of investigation. Because the renal functional benefit of PN is realized over many years and is the procedure is associated with a higher complication rate than RN, elderly patients may not receive the benefit of PN at the cost of higher risk. We sought to characterize perioperative, renal functional and oncologic outcomes of elderly patients undergoing surgery. METHODS: Our institutional renal mass registry was queried for patients > 65 years who underwent PN or RN. Clinicopathologic features and perioperative outcomes were compared between groups. Renal function outcomes as measured by change in GFR and freedom from GFR < 45 were analyzed. Overall survival (OS) and cancer-specific survival (CSS) were compared using the Kaplan-Meier method and Cox proportional hazard regression. RESULTS: Overall, 889 patients met inclusion criteria. Of these 441 (49.6) underwent PN and 448 (50.4) underwent RN. Patients undergoing RN tended to be older (median age 71.9 vs 70.3 years, p < 0.001), had larger tumors (5.5 vs 2.8 cm, p < 0.001), a higher proportion of RCC (89.8% vs 76.6%m p < 0.001) but had similar ASA scores (median score 3 vs 3, p ¼0.1). There were no difference in between RN and PN in terms of operative time (median time 186 vs 195 minutes, p¼0.5), median estimated blood loss (200 vs 200, p ¼ 0.7). Complications rates were similar for RN and PN (overall 51.5% vs 48.5%, p ¼ 0.5 ; Clavien I-II 30.9 vs26.9%, p ¼0.2, Clavien III-IV 8.9% vs 10.8%, p ¼0.2 ). RN was associated with a greater median change in GFR on last follow-up (19.2 vs 7.6, p < 0.001) and freedom from GFR<45 (53.2% vs 24.7%, p<0.001). On multivariable analysis controlling for tumor diameter, pathologic stage and ASA score, PN was associated with improved OS (HR 0.57, 95%CI 0.39-0.82, p < 0.001) and CSS (HR 0.26, 95%CI.09-0.73, p ¼ 0.01). CONCLUSIONS: In this series, PN was associated with similar perioperative outcomes as RN, but with superior. renal functional outcomes. Both OS and CSS favored PN, though selection bias likely exist. These data suggest that elderly patients may benefit from PN and age alone should not be a contraindication to nephron-sparing surgery. Source of Funding: None
MP84-04 GENDER AND RACIAL DISPARITIES IN UTILIZATION OF PARTIAL NEPHRECTOMY FOR RENAL MASSES Shane Pearce*, Zoe Steinberg, Chicago, IL; Richard Zigeuner, Graz, Austria; Chaidir Mochtar, Jakarta, Indonesia; Guillermo Gueglio, Buenos Aires, Argentina; Arieh Shalhav, Scott Eggener, Chicago, IL; M. Pilar Laguna, Amsterdam, Netherlands INTRODUCTION AND OBJECTIVES: Our objective was to assess for gender and racial disparities in the use of partial nephrectomy (PN) in a large, contemporary global population treated for renal masses. METHODS: The Clinical Research Office of the Endourological Society (CROES) Global Renal Mass Study is a prospective database of consecutive patients with renal masses treated during a 1-year period at 98 centers worldwide. Epidemiologic, clinical and pathologic data were compared between genders, limiting analysis to patients undergoing radical nephrectomy (RN) or PN. Multivariable regression analysis was performed to calculate odds of undergoing PN. RESULTS: Subjects (n¼3,625) included 2,332 men (64%) and 1,293 women (36%). PN was performed in 43% and 40% of women and
e1059
men, respectively (p¼0.14). The cohort was 84% Caucasian, 10% Asian, 2% African-American, and 4% Latin-American. Mean age was 61 13 and 68% presented with an incidentally detected mass with no significant differences between men and women (p>0.05). Comparing men to women, there was no difference in tumor size > 4cm (58% vs 58% p¼0.8), tumor location (p¼0.6), percent exophytic (p¼0.7), clinical T stage (p¼0.1) and clinical N stage (p¼0.2). Women were more likely to be pT1 (67% vs 62%, p<0.01) and have benign pathology (17% vs 9% p<0.01). On multivariable analysis, independent predictors of undergoing PN included female gender (OR 1.23 p¼0.05), tumor size < 4cm (OR 10.0 p<0.01), multiple tumors (OR 2.27, p¼0.01) and increasing percent exophytic (25-50%: OR 1.45 p<0.01; 51-75%: OR 2.70 p<0.01; >75%: OR 2.70 p<0.01). Factors associated with reduced odds of PN include African-American race (OR 0.38 p¼0.01), age (OR 0.97 p<0.01), symptomatic mass (0.29 p<0.01), mid-pole location (OR 0.73 p¼0.02), and hilar location (OR 0.28 p<0.01). CONCLUSIONS: This study identified multiple clinical predictors for utilization of partial nephrectomy in a large, contemporary database. Female gender increased odds of undergoing partial nephrectomy, while African-American race independently reduced likelihood of partial nephrectomy. Further research is needed to characterize these disparities and facilitate uniform care delivery. Source of Funding: The Global Renal Mass Study was supported by an unrestricted educational grant from STORZ.
MP84-05 VARIATION IN SURGICAL MARGIN STATUS BY SURGICAL APPROACH AMONG PATIENTS UNDERGOING PARTIAL NEPHRECTOMY FOR SMALL RENAL MASSES Jonathan E. Kiechle, Robert Abouassaly, William Tabayoyong*, Shan Dong, Cleveland, OH; Marc C. Smaldone, Philadelphia, PA; Edward E. Cherullo, Cleveland, OH; Cary P. Gross, New Haven, CT; Nilay D. Shah, Rochester, MN; Hui Zhu, Simon P. Kim, Cleveland, OH INTRODUCTION AND OBJECTIVES: Clinical guidelines recommend partial nephrectomy (PN) for small renal masses (SRM’s) when technically feasible. However, the introduction of laparoscopy and robotic surgery has changed the use of PN. It is unknown whether surgical margins, which can be viewed as a quality indicator, have been affected by the introduction of new surgical approaches. Therefore, we sought to assess the relationship of surgical margin status among patients undergoing PN for SRM from a population-based cohort. METHODS: We used the National Cancer Database to identify all patients who received a PN in 2010 and 2011. The primary outcome was the incidence of positive surgical margins for PN for open and minimally invasive surgical approaches. Multivariable logistic regression analysis was used to identify patient and hospital factors associated with positive surgical margins for PN. RESULTS: Among 15,469 patients who underwent PN, 45% (n¼6,958) had an open PN, 14% (n¼2,163) laparoscopic PN, and 37.6% (n¼5816) robotic PN. The overall prevalence of positive margins was 7.1%. The prevalence of positive margins was 5.5%, 8.1%, and 8.7% for open, laparoscopic, and robotic PN, respectively (p < 0.001). When compared to the open approach, there were higher adjusted odds ratios for positive surgical margins for laparoscopic PN (OR: 1.6; p<0.001) and for robotic PN (OR: 1.6; p<0.001). When stratified by hospital type, differences in positive margin rates remained with minimally invasive techniques such that patients treated at academic medical centers who underwent laparoscopic (OR 1.4; p ¼ 0.02) or robotic (OR 1.6; p <0.001) PN had higher adjusted odds ratios compared to patients treated with open surgery. CONCLUSIONS: Both minimally-invasive approaches for PN are associated with higher rates of positive surgical margins for SRM’s. Follow-up studies will help establish if these differences persist longterm or if they are related to the initial learning curve associated with the introduction of these relatively novel surgical approaches. Source of Funding: None