Wednesday, March 11, 2015

#NephMadness #OncoRegion Nephron Sparing VS Nephrectomy for Kidney Cancer Surgery Abstracts

Urology. 2014 Jan;83(1):111-5. doi: 10.1016/j.urology.2013.08.059. Epub 2013 Oct 11.

Laparoscopic partial nephrectomy for hilar tumors: oncologic and renal functional outcomes.

George AK(1), Herati AS(2), Rais-Bahrami S(2), Waingankar N(2), Kavoussi LR(2).

Author information:
(1)The Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of
Medicine, New Hyde Park, NY. Electronic address: (2)The
Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of Medicine,
New Hyde Park, NY.

OBJECTIVE: To present our experience with laparoscopic partial nephrectomy (LPN)
for hilar tumors and evaluate intermediate oncologic and renal functional
MATERIALS AND METHODS: A retrospective review of LPN cases performed in 488
patients was performed. Hilar lesions were defined as renal cortical tumors in
direct physical contact with the renal artery, vein, or both, as identified on
preoperative imaging and confirmed intraoperatively. The clinicopathologic
parameters, perioperative course, complications, and oncologic and 6-month renal
functional outcomes were analyzed.
RESULTS: A total of 488 patients underwent LPN, of which 43 were hilar. The mean
tumor size for hilar and nonhilar tumors was 3.6 cm and 3.1 cm, respectively. The
mean operative time was shorter for hilar as compared with nonhilar tumors (129.1
minutes vs 141.8 minutes). Mean estimated blood loss was greater in LPN for hilar
tumors (311.65 mL vs 298.4 mL). There were no statistically significant
differences noted in any of the perioperative parameters investigated despite a
higher nephrometry complexity score in the hilar group. Change in estimated
glomerular filtration rate at 6 months showed a decrease of 10.9 mL/min and 8.8
mL/min for hilar and nonhilar tumors, respectively (P = NS). There was 1
recurrence detected in the hilar group, with a median follow-up of 41.6 months.
CONCLUSION: In the hands of an experienced laparoscopist, LPN can safely be
performed for hilar tumors, with preservation of perioperative outcomes and
durable renal functional and oncologic outcomes.

Copyright © 2014 Elsevier Inc. All rights reserved.

PMID: 24119677  [PubMed - indexed for MEDLINE]

Eur Urol. 2011 Apr;59(4):543-52. doi: 10.1016/j.eururo.2010.12.013. Epub 2010 Dec22.

A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma.

Van Poppel H(1), Da Pozzo L, Albrecht W, Matveev V, Bono A, Borkowski A, Colombel
M, Klotz L, Skinner E, Keane T, Marreaud S, Collette S, Sylvester R.

Author information:
(1)Department of Urology, University Hospital Gasthuisberg, Katholieke
Universiteit Leuven, Leuven, Belgium.

Comment in
    Eur Urol. 2011 Aug;60(2):e9; author reply e10.
    Eur Urol. 2012 Apr;61(4):e37-8.
    Eur Urol. 2012 Sep;62(3):564-5.
    Eur Urol. 2013 Feb;63(2):399-400.
    Eur Urol. 2011 Apr;59(4):553-5.

BACKGROUND: Nephron-sparing surgery (NSS) can safely be performed with slightly
higher complication rates than radical nephrectomy (RN), but proof of oncologic
effectiveness is lacking.
OBJECTIVE: To compare overall survival (OS) and time to progression.
DESIGN, SETTING, AND PARTICIPANTS: From March 1992 to January 2003, when the
study was prematurely closed because of poor accrual, 541 patients with small (≤5
cm), solitary, T1-T2 N0 M0 (Union Internationale Contre le Cancer [UICC] 1978)
tumours suspicious for renal cell carcinoma (RCC) and a normal contralateral
kidney were randomised to NSS or RN in European Organisation for Research and
Treatment of Cancer Genito-Urinary Group (EORTC-GU) noninferiority phase 3 trial
INTERVENTION: Patients were randomised to NSS (n=268) or RN (n=273) together with
limited lymph node dissection (LND).
MEASUREMENTS: Time to event end points was compared with log-rank test results.
RESULTS AND LIMITATIONS: Median follow-up was 9.3 yr. The intention-to-treat
(ITT) analysis showed 10-yr OS rates of 81.1% for RN and 75.7% for NSS. With a
hazard ratio (HR) of 1.50 (95% confidence interval [CI], 1.03-2.16), the test for
noninferiority is not significant (p=0.77), and test for superiority is
significant (p=0.03). In RCC patients and clinically and pathologically eligible
patients, the difference is less pronounced (HR=1.43 and HR=1.34, respectively),
and the superiority test is no longer significant (p=0.07 and p=0.17,
respectively). Only 12 of 117 deaths were the result of renal cancer (four RN and
eight NSS). Twenty-one patients progressed (9 after RN and 12 after NSS). Quality
of life and renal function outcomes have not been addressed.
CONCLUSIONS: Both methods provide excellent oncologic results. In the ITT
population, NSS seems to be significantly less effective than RN in terms of OS.
However, in the targeted population of RCC patients, the trend in favour of RN is
no longer significant. The small number of progressions and deaths from renal
cancer cannot explain any possible OS differences between treatment types.

Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All
rights reserved.

PMID: 21186077  [PubMed - indexed for MEDLINE]

JAMA. 2012 Apr 18;307(15):1629-35. doi: 10.1001/jama.2012.475.

Long-term survival following partial vs radical nephrectomy among older patients with early-stage kidney cancer.

Tan HJ(1), Norton EC, Ye Z, Hafez KS, Gore JL, Miller DC.

Author information:
(1)Dow Division of Health Services Research, Department of Urology, University of
Michigan, Ann Arbor, MI 48109-2800, USA.

Comment in
    Eur Urol. 2012 Aug;62(2):352-3.
    JAMA. 2012 Apr 18;307(15):1641-3.
    Urol Oncol. 2013 Jan;31(1):126-7.
    J Urol. 2012 Nov;188(5):1723-4.

CONTEXT: Although partial nephrectomy is the preferred treatment for many
patients with early-stage kidney cancer, recent clinical trial data, which
demonstrate better survival for patients treated with radical nephrectomy, have
generated new uncertainty regarding the comparative effectiveness of these
treatment options.
OBJECTIVE: To compare long-term survival after partial vs radical nephrectomy
among a population-based patient cohort whose treatment reflects contemporary
surgical practice.
DESIGN, SETTING, AND PATIENTS: We performed a retrospective cohort study of
Medicare beneficiaries with clinical stage T1a kidney cancer treated with partial
or radical nephrectomy from 1992 through 2007. Using an instrumental variable
approach to account for measured and unmeasured differences between treatment
groups, we fit a 2-stage residual inclusion model to estimate the treatment
effect of partial nephrectomy on long-term survival.
MAIN OUTCOME MEASURES: Overall and kidney cancer-specific survival.
RESULTS: Among 7138 Medicare beneficiaries with early-stage kidney cancer, we
identified 1925 patients (27.0%) treated with partial nephrectomy and 5213
patients (73.0%) treated with radical nephrectomy. During a median follow-up of
62 months, 487 (25.3%) and 2164 (41.5%) patients died following partial or
radical nephrectomy, respectively. Kidney cancer was the cause of death for 37
patients (1.9%) treated with partial nephrectomy, and 222 patients (4.3%) treated
with radical nephrectomy. Patients treated with partial nephrectomy had a
significantly lower risk of death (hazard ratio [HR], 0.54; 95% CI, 0.34-0.85).
This corresponded with a predicted survival increase with partial nephrectomy of
5.6 (95% CI, 1.9-9.3), 11.8 (95% CI, 3.9-19.7), and 15.5 (95% CI, 5.0-26.0)
percentage points at 2, 5, and 8 years posttreatment (P < .001). No difference
was noted in kidney cancer-specific survival (HR, 0.82; 95% CI, 0.19-3.49).
CONCLUSION: Among Medicare beneficiaries with early-stage kidney cancer who were
candidates for either surgery, treatment with partial rather than radical
nephrectomy was associated with improved survival.

PMCID: PMC3864575
PMID: 22511691  [PubMed - indexed for MEDLINE]

Eur Urol. 2014 Feb;65(2):372-7. doi: 10.1016/j.eururo.2013.06.044. Epub 2013 Jul 2.

Renal function after nephron-sparing surgery versus radical nephrectomy: results from EORTC randomized trial 30904.

Scosyrev E(1), Messing EM(2), Sylvester R(3), Campbell S(4), Van Poppel H(5).

Author information:
(1)Department of Urology, University of Rochester Medical Center, Rochester, NY,
USA. (2)Department of Urology, University of Rochester Medical Center, Rochester,
NY, USA. Electronic address: (3)Department of
Biostatistics, EORTC Headquarters, Brussels, Belgium. (4)Department of Urology,
Cleveland Clinic, Cleveland, OH, USA. (5)Department of Urology, University
Hospital K.U. Leuven, Leuven, Belgium.

Comment in
    J Urol. 2014 Aug;192(2):369-70.
    Eur Urol. 2014 Feb;65(2):378-9; discussion 379-80.

BACKGROUND: In the European Organization for Research and Treatment of Cancer
(EORTC) randomized trial 30904, nephron-sparing surgery (NSS) was associated with
reduced overall survival compared with radical nephrectomy (RN) over a median
follow-up of 9.3 yr (hazard ratio: 1.50; 95% confidence interval [CI],
OBJECTIVE: To examine the impact of NSS relative to RN on kidney function in
EORTC 30904.
DESIGN, SETTING, AND PARTICIPANTS: This phase 3 international randomized trial
was conducted in patients with a small (≤5 cm) renal mass and normal
contralateral kidney who were enrolled from March 1992 to January 2003.
INTERVENTION: Patients were randomized to RN (n=273) or NSS (n=268).
filtration rates (eGFR; milliliters per minute per 1.73 m(2)) were recorded for
259 subjects in the RN arm and 255 subjects in the NSS arm. Percentages of
subjects developing at least moderate renal dysfunction (eGFR <60 advanced="" br="">kidney disease (eGFR <30 br="" calculated="" each="" egfr="" failure="" for="" kidney="" or="" were="">treatment arm based on the lowest recorded follow-up eGFR (intent-to-treat
RESULTS AND LIMITATIONS: With a median follow-up of 6.7 yr, eGFR <60 br="" reached="" was="">by 85.7% with RN and 64.7% with NSS, with a difference of 21.0% (95% CI,
13.8-28.3); eGFR <30 10.0="" 6.3="" a="" and="" br="" by="" nss="" reached="" rn="" was="" with="">difference of 3.7% (95% CI, -1.0 to 8.5); and eGFR <15 1.5="" br="" by="" reached="" was="" with="">RN and 1.6% with NSS, with a difference of -0.1% (95% CI, -2.2 to 2.1). Lack of
longer follow-up for eGFR is a limitation of these analyses.
CONCLUSIONS: Compared with RN, NSS substantially reduced the incidence of at
least moderate renal dysfunction (eGFR <60 although="" available="" br="" follow-up="" with="">the incidence of advanced kidney disease (eGFR <30 br="" in="" relatively="" similar="" the="" was="">two treatment arms, and the incidence of kidney failure (eGFR <15 br="" nearly="" was="">identical. The beneficial impact of NSS on eGFR did not result in improved
survival in this study population.
REGISTRATION: EORTC trial 30904; identifier NCT00002473.

Copyright © 2013 European Association of Urology. Published by Elsevier B.V. All
rights reserved.

PMID: 23850254  [PubMed - indexed for MEDLINE]


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