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PD20-09 SURGICAL APPROACH DOES NOT IMPACT POSITIVE MARGIN RATE IN PARTIAL NEPHRECTOMY FOR LARGE RENAL MASSES
THE JOURNAL OF UROLOGYâ
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PD20-09 SURGICAL APPROACH DOES NOT IMPACT POSITIVE MARGIN RATE IN PARTIAL NEPHRECTOMY FOR LARGE RENAL MASSES Abimbola Ayangbesan*, David Golombos, New York, NY; Padraic O’Malley, Halifax, Canada; Patrick Lewicki, LaMont Barlow, Xian Wu, Paul Christos, Douglas Scherr, New York, NY INTRODUCTION AND OBJECTIVES: Utilization of partial nephrectomy (PNx) has expanded to include treatment of an increasing number of renal masses 4cm by various surgical approaches. Recent evidence has suggested risk of recurrence with positive surgical margin (PSM) is increased in the presence of high-risk features, including stage T2. While surgical approach has been associated with PSM in PNx for small renal masses (<4 cm), its impact on margin status for large renal masses is unclear. METHODS: Using the National Cancer Data Base (NCDB), we identified patients undergoing PNx for clinical T1b and T2a renal cell carcinoma (RCC) from 2011 to 2013. Primary outcome was surgical margin status. Multivariable regression modeling was performed to identify patient, facility, and surgical factors, including surgical approach (open, laparoscopic, or robotic) on PSM in patients undergoing PNx. RESULTS: Of 7495 undergoing PNx for cT1b and T2a renal masses from 2011 to 2013, 504 (6.72%) had PSM. On multivariable analysis, age > 60 years (OR 1.57 [95% CI 1.01-2.44] p¼0.048), African American race (OR 1.52 [95% CI 1.06-2.17] p¼0.023), education level (OR 1.48 [95% CI 1.03-2.14] p¼0.034), rural setting (OR 4.82 [95% CI 2.459.46] p<0.01), mixed histology (OR 1.84 [95% CI 1.04-3.24] p¼0.035), undifferentiated tumor grade (OR 2.42 [95% CI 1.26-4.65] p<0.01), as well as having surgery performed at a non-academic facility (OR 1.57 [95% CI 1.15-2.15] p<0.01) were associated with PSM. Surgical approach (laparoscopic and robotic vs. open) (p¼0.119 and p¼0.437, respectively) and stage (T2a vs. T1b) (p¼0.182) were not associated with PSM. CONCLUSIONS: Surgical approach is not independently associated with increased risk of PSM for large renal masses, which is contrary to previous reports pertaining to cT1a lesions. Surgery at an academic facility was protective against having a positive margin. These data are important given the unclear oncologic significance of margin status in these tumors. Source of Funding: None
PD20-10 DOES TUMOR COMPLEXITY HAVE AN IMPACT ON MIC AND TRIFECTA OUTCOME IN ROBOT-ASSISTED PARTIAL NEPHRECTOMY? A MULTI-CENTER STUDY OF OVER 500 CASES Nina Harke*, Rostock, Germany; Christian Wagner, Gronau, Germany; Alexander Roosen, Bochum, Germany; Frank Schiefelbein, Wuerzburg, Germany; Burkhard Ubrig, Bochum, Germany; Georg Schoen, Wuerzburg, Germany; Jorn H. Witt, Gronau, Germany INTRODUCTION AND OBJECTIVES: Partial nephrectomy is standard of care for renal tumors up to 7 cm and there is a widespread use of the minimal invasive approach since the introduction of robotassisted surgery. However, there might still be some reservations in complex tumor constellations. Our study aims to demonstrate that robot-assisted partial nephrectomy (RAPN) provides good results for high risk tumors in comparison with less complex renal masses. METHODS: Since 2008, 538 robot-assisted partial nephrectomies were performed at Missionsaerztliche Klinik, Wuerzburg (n¼361), St. Antonius Hospital, Gronau (n¼60), and Augusta-KrankenAnstalt Bochum (n¼117). To assess functional and oncological outcome, both MIC criteria (negative margins, ischemia time < 20 minutes, no major complications) as well as the Trifecta (negative surgical margins, WIT < 25 minutes, no complications) were applied. RESULTS: 60,6% of the tumors were of low and intermediate complexity (PADUA score 6-7, n¼123, score 8-9, n¼203, group A) while
Vol. 197, No. 4S, Supplement, Saturday, May 13, 2017
39,4% were highly complex (score 10-12, B). There were no significant differences in ASA score or BMI. Median clinical tumor size was 28 in the low vs. 37 mm in in the high complexity group (p<0,001). While there was no significantly prolonged skin-skin time (160 vs. 163 minutes, p¼0,17), ischemia time was shorter for tumors of low and intermediate complexity (11 vs. 12 minutes, p<0,001). More intraoperative transfusions were necessary in the high risk group (0 vs. 3, p¼0,06). Neither intra- (3,4 vs. 6,6%) nor postoperative (Clavien-Dindo, 21% vs. 25%, p¼0,3) complication rates showed significant differences between both groups. On postoperative day 1, a median decrease of hemoglobin of -2,4 g/dl was found in B vs. -2,2 g/dl (p¼0,042) in group A. There was a median creatinine increase of 0,10 vs. 0,17 mg/dl (p<0,001) and loss of eGFR of 9,4 vs. 15,1 ml/min (p<0,001) on demission. Benign tumors were found in 26% of the patients with low/intermediate-risk lesions vs. 21% in the high complexity group. In 3% of high complexity tumors a positive surgical margin (R1) with 3% Rx vs. 2% and 2% for A was found (p¼0,29). MIC criteria could be achieved in 82% (A) vs. 76% (B, p¼0,80) and Trifecta criteria in 74% (A) vs. 69% (B, p¼0,20). CONCLUSIONS: Significant differences between high and low complexity groups could only be identified in ischemia time and renal function. However, complication rates as well as quality criteria as indicated by MIC and Trifecta were similar in both groups. Therefore, RAPN is a very good therapeutic option also in highly complex tumors. Source of Funding: None
PD20-11 ACUTE KIDNEY INJURY AFTER PARTIAL NEPHRECTOMY: IMPACT ON LONG-TERM STABILITY OF RENAL FUNCTION Joseph Zabell*, Wen Dong, Diego Aguilar Palacios, Joseph Abraham, Sudhir Isharwal, Erick Remer, Steven C. Campbell, Cleveland, OH INTRODUCTION AND OBJECTIVES: Acute kidney injury (AKI) is associated with increased risk of developing chronic kidney disease (CKD) in the general population. AKI is frequently observed after partial nephrectomy (PN), however the long-term functional impact of AKI in this setting has not been adequately studied. METHODS: From 2004-2014, 90 solitary kidneys managed with PN had necessary studies for analysis of percent function and renal parenchyma preserved before and after surgery. Functional data including serum creatinine (SCr) and glomerular filtration rate (GFR) was required at all of the following time points: pre-operative (<3 months prior to PN), peak post-operative, new baseline (3-12 months post-operative), and long-term (>12 months post-operative). AKI was classified by RIFLE (Risk/Injury/ Failure/Loss/End-stage) defined by either standard criteria (comparison of peak SCr to preoperative SCr) or proposed criteria (comparison to projected postoperative SCr based on parenchymal mass reduction). Longterm functional deterioration was defined as decline in GFR >20% between new baseline and long-term follow-up, or need for dialysis >12 months post-operatively. Relationship between AKI grade and long-term functional outcomes was assessed by multivariable logistic regression, controlling for pertinent patient, tumor, and perioperative characteristics. RESULTS: Median age was 64 years. Median duration of follow-up was 45 (IQR¼29-90) months. Warm ischemia was used in 47% of patients, and overall median ischemia time was 29 minutes. Median parenchymal mass preservation was 80% and median GFR preserved was 79%. Based on standard criteria, AKI grade 1/2/3 occurred in 31%, 19%, and 18%, respectively, and analogous findings for the proposed criteria were 22%, 13%, and 7%. Fourteen (16%) patients experienced long-term functional decline. On multivariable analysis, presence of AKI and degree of AKI did not associated with long-term functional decline after PN, whether defined by standard or proposed criteria (all p>0.5). Limitations include retrospective design. CONCLUSIONS: AKI related to surgery (AKI-S) may not have the same adverse functional implications as AKI due to medical causes (AKI-M). AKI-M is typically due to longstanding medical comorbidities, such as CHF, while AKI-S is primarily due to a transient ischemia insult that will not be repeated. Additional study, with larger sample sizes and
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PD20-09 SURGICAL APPROACH DOES NOT IMPACT POSITIVE MARGIN RATE IN PARTIAL NEPHRECTOMY FOR LARGE RENAL MASSES Abimbola Ayangbesan*, David Golombos, New York, NY; Padraic O’Malley, Halifax, Canada; Patrick Lewicki, LaMont Barlow, Xian Wu, Paul Christos, Douglas Scherr, New York, NY INTRODUCTION AND OBJECTIVES: Utilization of partial nephrectomy (PNx) has expanded to include treatment of an increasing number of renal masses 4cm by various surgical approaches. Recent evidence has suggested risk of recurrence with positive surgical margin (PSM) is increased in the presence of high-risk features, including stage T2. While surgical approach has been associated with PSM in PNx for small renal masses (<4 cm), its impact on margin status for large renal masses is unclear. METHODS: Using the National Cancer Data Base (NCDB), we identified patients undergoing PNx for clinical T1b and T2a renal cell carcinoma (RCC) from 2011 to 2013. Primary outcome was surgical margin status. Multivariable regression modeling was performed to identify patient, facility, and surgical factors, including surgical approach (open, laparoscopic, or robotic) on PSM in patients undergoing PNx. RESULTS: Of 7495 undergoing PNx for cT1b and T2a renal masses from 2011 to 2013, 504 (6.72%) had PSM. On multivariable analysis, age > 60 years (OR 1.57 [95% CI 1.01-2.44] p¼0.048), African American race (OR 1.52 [95% CI 1.06-2.17] p¼0.023), education level (OR 1.48 [95% CI 1.03-2.14] p¼0.034), rural setting (OR 4.82 [95% CI 2.459.46] p<0.01), mixed histology (OR 1.84 [95% CI 1.04-3.24] p¼0.035), undifferentiated tumor grade (OR 2.42 [95% CI 1.26-4.65] p<0.01), as well as having surgery performed at a non-academic facility (OR 1.57 [95% CI 1.15-2.15] p<0.01) were associated with PSM. Surgical approach (laparoscopic and robotic vs. open) (p¼0.119 and p¼0.437, respectively) and stage (T2a vs. T1b) (p¼0.182) were not associated with PSM. CONCLUSIONS: Surgical approach is not independently associated with increased risk of PSM for large renal masses, which is contrary to previous reports pertaining to cT1a lesions. Surgery at an academic facility was protective against having a positive margin. These data are important given the unclear oncologic significance of margin status in these tumors. Source of Funding: None
PD20-10 DOES TUMOR COMPLEXITY HAVE AN IMPACT ON MIC AND TRIFECTA OUTCOME IN ROBOT-ASSISTED PARTIAL NEPHRECTOMY? A MULTI-CENTER STUDY OF OVER 500 CASES Nina Harke*, Rostock, Germany; Christian Wagner, Gronau, Germany; Alexander Roosen, Bochum, Germany; Frank Schiefelbein, Wuerzburg, Germany; Burkhard Ubrig, Bochum, Germany; Georg Schoen, Wuerzburg, Germany; Jorn H. Witt, Gronau, Germany INTRODUCTION AND OBJECTIVES: Partial nephrectomy is standard of care for renal tumors up to 7 cm and there is a widespread use of the minimal invasive approach since the introduction of robotassisted surgery. However, there might still be some reservations in complex tumor constellations. Our study aims to demonstrate that robot-assisted partial nephrectomy (RAPN) provides good results for high risk tumors in comparison with less complex renal masses. METHODS: Since 2008, 538 robot-assisted partial nephrectomies were performed at Missionsaerztliche Klinik, Wuerzburg (n¼361), St. Antonius Hospital, Gronau (n¼60), and Augusta-KrankenAnstalt Bochum (n¼117). To assess functional and oncological outcome, both MIC criteria (negative margins, ischemia time < 20 minutes, no major complications) as well as the Trifecta (negative surgical margins, WIT < 25 minutes, no complications) were applied. RESULTS: 60,6% of the tumors were of low and intermediate complexity (PADUA score 6-7, n¼123, score 8-9, n¼203, group A) while
Vol. 197, No. 4S, Supplement, Saturday, May 13, 2017
39,4% were highly complex (score 10-12, B). There were no significant differences in ASA score or BMI. Median clinical tumor size was 28 in the low vs. 37 mm in in the high complexity group (p<0,001). While there was no significantly prolonged skin-skin time (160 vs. 163 minutes, p¼0,17), ischemia time was shorter for tumors of low and intermediate complexity (11 vs. 12 minutes, p<0,001). More intraoperative transfusions were necessary in the high risk group (0 vs. 3, p¼0,06). Neither intra- (3,4 vs. 6,6%) nor postoperative (Clavien-Dindo, 21% vs. 25%, p¼0,3) complication rates showed significant differences between both groups. On postoperative day 1, a median decrease of hemoglobin of -2,4 g/dl was found in B vs. -2,2 g/dl (p¼0,042) in group A. There was a median creatinine increase of 0,10 vs. 0,17 mg/dl (p<0,001) and loss of eGFR of 9,4 vs. 15,1 ml/min (p<0,001) on demission. Benign tumors were found in 26% of the patients with low/intermediate-risk lesions vs. 21% in the high complexity group. In 3% of high complexity tumors a positive surgical margin (R1) with 3% Rx vs. 2% and 2% for A was found (p¼0,29). MIC criteria could be achieved in 82% (A) vs. 76% (B, p¼0,80) and Trifecta criteria in 74% (A) vs. 69% (B, p¼0,20). CONCLUSIONS: Significant differences between high and low complexity groups could only be identified in ischemia time and renal function. However, complication rates as well as quality criteria as indicated by MIC and Trifecta were similar in both groups. Therefore, RAPN is a very good therapeutic option also in highly complex tumors. Source of Funding: None
PD20-11 ACUTE KIDNEY INJURY AFTER PARTIAL NEPHRECTOMY: IMPACT ON LONG-TERM STABILITY OF RENAL FUNCTION Joseph Zabell*, Wen Dong, Diego Aguilar Palacios, Joseph Abraham, Sudhir Isharwal, Erick Remer, Steven C. Campbell, Cleveland, OH INTRODUCTION AND OBJECTIVES: Acute kidney injury (AKI) is associated with increased risk of developing chronic kidney disease (CKD) in the general population. AKI is frequently observed after partial nephrectomy (PN), however the long-term functional impact of AKI in this setting has not been adequately studied. METHODS: From 2004-2014, 90 solitary kidneys managed with PN had necessary studies for analysis of percent function and renal parenchyma preserved before and after surgery. Functional data including serum creatinine (SCr) and glomerular filtration rate (GFR) was required at all of the following time points: pre-operative (<3 months prior to PN), peak post-operative, new baseline (3-12 months post-operative), and long-term (>12 months post-operative). AKI was classified by RIFLE (Risk/Injury/ Failure/Loss/End-stage) defined by either standard criteria (comparison of peak SCr to preoperative SCr) or proposed criteria (comparison to projected postoperative SCr based on parenchymal mass reduction). Longterm functional deterioration was defined as decline in GFR >20% between new baseline and long-term follow-up, or need for dialysis >12 months post-operatively. Relationship between AKI grade and long-term functional outcomes was assessed by multivariable logistic regression, controlling for pertinent patient, tumor, and perioperative characteristics. RESULTS: Median age was 64 years. Median duration of follow-up was 45 (IQR¼29-90) months. Warm ischemia was used in 47% of patients, and overall median ischemia time was 29 minutes. Median parenchymal mass preservation was 80% and median GFR preserved was 79%. Based on standard criteria, AKI grade 1/2/3 occurred in 31%, 19%, and 18%, respectively, and analogous findings for the proposed criteria were 22%, 13%, and 7%. Fourteen (16%) patients experienced long-term functional decline. On multivariable analysis, presence of AKI and degree of AKI did not associated with long-term functional decline after PN, whether defined by standard or proposed criteria (all p>0.5). Limitations include retrospective design. CONCLUSIONS: AKI related to surgery (AKI-S) may not have the same adverse functional implications as AKI due to medical causes (AKI-M). AKI-M is typically due to longstanding medical comorbidities, such as CHF, while AKI-S is primarily due to a transient ischemia insult that will not be repeated. Additional study, with larger sample sizes and