Ahmet Bindayi1, Riccardo Autorino2, Umberto Capitanio3, Nicola Pavan4, Maria Carmen Mir5, Alessandro Antonelli6, Toshio Takagi7, Riccardo Bertolo8, Tobias Maurer9, Koon Ho Rha10, Jean Alexandre Long11, Bo Yang12, Luigi Schips13, Estevão Lima14, Alberto Breda15, Estefania Linares16, Antonio Celia17, Cosimo De Nunzio18, Ryan Dobbs19, Sunil Patel1, Zachary Hamilton1, Andrew Tracey2, Alessandro Larcher3, Carlo Trombetta4, Carlotta Palumbo6, Kazunari Tanabe7, Thomas Amiel9, Ali Raheem10, Gaelle Fiard11, Chao Zhang12, Roberto Castellucci13, Joan Palou15, Stephen Ryan1, Simone Crivellaro19, Francesco Montorsi3, Francesco Porpiglia8, Ithaar H Derweesh20. 1. Department ofUrology, University of California San Diego School of Medicine, La Jolla, CA, USA. 2. Department of Urology Virginia Commonwealth University, Richmond, VA, USA. 3. Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy. 4. Urology Clinic, University of Trieste, Trieste, Italy. 5. Instituto Valenciano de Oncologia, Valencia, Spain. 6. Department of Urology, Spedali Civili Hospital, Brescia, Italy. 7. Department of Urology, Tokyo Women's Medical University, Tokyo, Japan. 8. Department of Urology, University of Turin-San Luigi Gonzaga Hospital, Turin, Italy. 9. Department of Urology, Technical University of Munich, Munich, Germany. 10. Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea. 11. Department of Urology, University of Grenoble, Grenoble, France. 12. Department of Urology, Changhai Hospital, Shanghai, China. 13. Division of Urology, ASL Abruzzo 2, Chieti, Italy. 14. CUF Urology, University of Minho, Braga, Portugal. 15. Department of Urology, Autonoma University of Barcelona, Barcelona, Spain. 16. Department of Urology, Hospital Universitario La Paz, Madrid, Spain. 17. Department of Urology, San Bassiano Hospital, Bassano del Grappa, Italy. 18. Department of Urology, Sant'Andrea Hospital, University La Sapienza, Rome, Italy. 19. Department of Urology, University of Illinois-Chicago, Chicago, IL, USA. 20. Department ofUrology, University of California San Diego School of Medicine, La Jolla, CA, USA. Electronic address: iderweesh@gmail.com.
Abstract
BACKGROUND: Partial nephrectomy (PN) in elderly patients is underutilized with concerns regarding risk of complications and potential for poor outcomes. OBJECTIVE: To evaluate quality and functional outcomes of PN in patients >75 yr using trifecta as a composite outcome of surgical quality. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective analysis of 653 patients aged >75 yr who underwent PN (REnal SURGery in Elderly [RESURGE] Group). INTERVENTION: PN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was achievement of trifecta (negative margin, no major [Clavien ≥3] urological complications, and ≥90% estimated glomerular filtration rate [eGFR] recovery). Secondary outcomes included chronic kidney disease (CKD) stage III and CKD upstaging. Multivariable analysis (MVA) was used to assess variables for achieving trifecta and functional outcomes. Kaplan-Meier survival analysis (KMA) was used to calculate renal functional outcomes. RESULTS AND LIMITATIONS: We analyzed 653 patients (mean age 78.4 yr, median follow-up 33 mo; 382 open, 157 laparoscopic, and 114 robotic). Trifecta rate was 40.4% (n=264). Trifecta patients had less transfusion (p<0.001), lower intraoperative (5.3% vs 27%, p<0.001) and postoperative (25.4% vs 37.8%, p=0.001) complications, shorter hospital stay (p=0.045), and lower ΔeGFR (p <0.001). MVA for predictive factors for trifecta revealed decreasing RENAL nephrometry score (odds ratio [OR] 1.26, 95% confidence interval 1.07-1.51, p=0.007) as being associated with increased likelihood to achieve trifecta. Achievement of trifecta was associated with decreased risk of CKD upstaging (OR 0.47, 95% confidence interval 0.32-0.62, p<0.001). KMA showed that trifecta patients had improved 5-yr freedom from CKD stage 3 (93.5% vs 57.7%, p<0.001) and CKD upstaging (84.3% vs 8.2%, p<0.001). Limitations include retrospective design. CONCLUSIONS: PN in elderly patients can be performed with acceptable quality outcomes. Trifecta was associated with decreased tumor complexity and improved functional preservation. PATIENT SUMMARY: We looked at quality outcomes after partial nephrectomy in elderly patients. Acceptable quality outcomes were achieved, measured by a composite outcome called trifecta, whose achievement was associated with improved kidney functional preservation.
BACKGROUND: Partial nephrectomy (PN) in elderly patients is underutilized with concerns regarding risk of complications and potential for poor outcomes. OBJECTIVE: To evaluate quality and functional outcomes of PN in patients >75 yr using trifecta as a composite outcome of surgical quality. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective analysis of 653 patients aged >75 yr who underwent PN (REnal SURGery in Elderly [RESURGE] Group). INTERVENTION: PN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was achievement of trifecta (negative margin, no major [Clavien ≥3] urological complications, and ≥90% estimated glomerular filtration rate [eGFR] recovery). Secondary outcomes included chronic kidney disease (CKD) stage III and CKD upstaging. Multivariable analysis (MVA) was used to assess variables for achieving trifecta and functional outcomes. Kaplan-Meier survival analysis (KMA) was used to calculate renal functional outcomes. RESULTS AND LIMITATIONS: We analyzed 653 patients (mean age 78.4 yr, median follow-up 33 mo; 382 open, 157 laparoscopic, and 114 robotic). Trifecta rate was 40.4% (n=264). Trifecta patients had less transfusion (p<0.001), lower intraoperative (5.3% vs 27%, p<0.001) and postoperative (25.4% vs 37.8%, p=0.001) complications, shorter hospital stay (p=0.045), and lower ΔeGFR (p <0.001). MVA for predictive factors for trifecta revealed decreasing RENAL nephrometry score (odds ratio [OR] 1.26, 95% confidence interval 1.07-1.51, p=0.007) as being associated with increased likelihood to achieve trifecta. Achievement of trifecta was associated with decreased risk of CKD upstaging (OR 0.47, 95% confidence interval 0.32-0.62, p<0.001). KMA showed that trifecta patients had improved 5-yr freedom from CKD stage 3 (93.5% vs 57.7%, p<0.001) and CKD upstaging (84.3% vs 8.2%, p<0.001). Limitations include retrospective design. CONCLUSIONS: PN in elderly patients can be performed with acceptable quality outcomes. Trifecta was associated with decreased tumor complexity and improved functional preservation. PATIENT SUMMARY: We looked at quality outcomes after partial nephrectomy in elderly patients. Acceptable quality outcomes were achieved, measured by a composite outcome called trifecta, whose achievement was associated with improved kidney functional preservation.
Authors: M T Walach; M F Wunderle; N Haertel; J K Mühlbauer; K F Kowalewski; N Wagener; N Rathmann; M C Kriegmair Journal: World J Urol Date: 2021-01-30 Impact factor: 4.226