Eduard Roussel1, Riccardo Campi2, Alessandro Larcher3, Annelies Verbiest4, Alessandro Antonelli5, Carlotta Palumbo5, Ithaar Derweesh6, Fady Ghali6, Aaron Bradshaw6, Margaret F Meagher6, Matthias Heck7, Thomas Amiel7, Maximilian C Kriegmair8, Jose Rubio9, Mireia Musquera10, Maurizio D'Anna10, Riccardo Autorino11, Georgi Guruli11, Alessandro Veccia11, Estefania Linares-Espinos12, Siska Van Bruwaene13, Vital Hevia14, Francesco Porpiglia15, Enrico Checcucci15, Andrea Minervini2, Andrea Mari2, Nicola Pavan16, Francesco Claps15, Michele Marchioni17, Umberto Capitanio3, Benoit Beuselinck4, Maria C Mir18, Maarten Albersen1. 1. Department of Urology, University Hospitals Leuven, Leuven, Belgium. 2. Department of Urology, University of Florence, Careggi Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy. 3. Department of Urology, San Raffaele Scientific Institute, Milan, Italy. 4. Department of Medical Oncology, University Hospitals Leuven, Leuven, Belgium. 5. Department of Urology, Spedali Civili Hospital, University of Brescia, Brescia, Italy. 6. Department of Urology, University of California San Diego Cancer Center, Lousiana Jolla, CA, USA. 7. Department of Urology, Technical University of Munich, Munich, Germany. 8. Department of Urology, University Medical Centre Mannheim, Mannheim, Germany. 9. Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain. 10. Department of Urology, Hospital Clinic, Barcelona, Spain. 11. Department of Urology, VCU Medical Center, Richmond, VA, USA. 12. Department of Urology, Hospital La Paz, Madrid, Spain. 13. Department of Urology, AZ Groeninge, Kortrijk, Belgium. 14. Department of Urology, Hospital Ramon y Cajal, Madrid, Spain. 15. Department of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy. 16. Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy. 17. Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, "G. d'Annunzio" University of Chieti, Chieti, Italy; Department of Urology, SS Annunziata Hospital, "G. D'Annunzio" University of Chieti, Chieti, Italy. 18. Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain. Electronic address: mirmare@yahoo.es.
Abstract
BACKGROUND: Cytoreductive nephrectomy (CN) plays an important role in the treatment of a subgroup of metastatic renal cell carcinoma (mRCC) patients. OBJECTIVE: We aimed to evaluate morbidity associated with this procedure and identify potential predictors thereof to aid patient selection for this procedure and potentially improve patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: Data from 736 mRCC patients undergoing CN at 14 institutions were retrospectively recorded in the Registry for Metastatic RCC (REMARCC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Logistic regression analysis was used to identify predictors for intraoperative, any-grade (AGCs), low-grade, and high-grade (HGCs) postoperative complications (according to the Clavien-Dindo classification) as well as 30-d readmission rates. RESULTS AND LIMITATIONS: Intraoperative complications were observed in 69 patients (10.9%). Thrombectomy (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.08-1.75, p = 0.009) and adjacent organ removal (OR 2.7, 95% CI 1.38-5.30) were significant predictors of intraoperative complications at multivariable analysis. Two hundred seventeen patients (29.5%) encountered AGCs, while 45 (6.1%) encountered an HGC, of whom 10 (1.4%) died. Twenty-four (3.3%) patients had multiple postoperative complications. Estimated blood loss (EBL; OR 1.49, 95% CI 1.08-2.05, p = 0.01) was a significant predictor of AGCs at multivariable analysis. CN case load (OR 0.13, 95% CI 0.03-0.59, p = 0.009) and EBL (OR 2.93, 95% CI 1.20-7.15, p = 0.02) were significant predictors solely for HGCs at multivariable analysis. Forty-one patients (11.5%) were readmitted within 30 d of surgery. No significant predictors were identified. Results were confirmed in a subanalysis focusing solely on patients treated in the contemporary targeted therapy era. CONCLUSIONS: Morbidity associated with CN is not negligible. Predictors of high-grade postoperative morbidity are predominantly indicators of complex surgery. EBL is a strong predictor of postoperative complications. CN case load correlates with lower high-grade morbidity and highlights the benefit of centralization of complex surgery. However, risks and benefits should be balanced when considering CN in mRCC patients. PATIENT SUMMARY: We studied patients with metastatic renal cancer to evaluate the outcomes associated with the surgical removal of the primary kidney tumor. We found that this procedure is often complex and adverse events are not uncommon. High intraoperative blood loss and a small number of cases performed at the treating center are associated with a higher rate of postoperative complications.
BACKGROUND: Cytoreductive nephrectomy (CN) plays an important role in the treatment of a subgroup of metastatic renal cell carcinoma (mRCC) patients. OBJECTIVE: We aimed to evaluate morbidity associated with this procedure and identify potential predictors thereof to aid patient selection for this procedure and potentially improve patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: Data from 736 mRCC patients undergoing CN at 14 institutions were retrospectively recorded in the Registry for Metastatic RCC (REMARCC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Logistic regression analysis was used to identify predictors for intraoperative, any-grade (AGCs), low-grade, and high-grade (HGCs) postoperative complications (according to the Clavien-Dindo classification) as well as 30-d readmission rates. RESULTS AND LIMITATIONS: Intraoperative complications were observed in 69 patients (10.9%). Thrombectomy (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.08-1.75, p = 0.009) and adjacent organ removal (OR 2.7, 95% CI 1.38-5.30) were significant predictors of intraoperative complications at multivariable analysis. Two hundred seventeen patients (29.5%) encountered AGCs, while 45 (6.1%) encountered an HGC, of whom 10 (1.4%) died. Twenty-four (3.3%) patients had multiple postoperative complications. Estimated blood loss (EBL; OR 1.49, 95% CI 1.08-2.05, p = 0.01) was a significant predictor of AGCs at multivariable analysis. CN case load (OR 0.13, 95% CI 0.03-0.59, p = 0.009) and EBL (OR 2.93, 95% CI 1.20-7.15, p = 0.02) were significant predictors solely for HGCs at multivariable analysis. Forty-one patients (11.5%) were readmitted within 30 d of surgery. No significant predictors were identified. Results were confirmed in a subanalysis focusing solely on patients treated in the contemporary targeted therapy era. CONCLUSIONS: Morbidity associated with CN is not negligible. Predictors of high-grade postoperative morbidity are predominantly indicators of complex surgery. EBL is a strong predictor of postoperative complications. CN case load correlates with lower high-grade morbidity and highlights the benefit of centralization of complex surgery. However, risks and benefits should be balanced when considering CN in mRCC patients. PATIENT SUMMARY: We studied patients with metastatic renal cancer to evaluate the outcomes associated with the surgical removal of the primary kidney tumor. We found that this procedure is often complex and adverse events are not uncommon. High intraoperative blood loss and a small number of cases performed at the treating center are associated with a higher rate of postoperative complications.
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