ELECTIVE PARTIAL NEPHRECTOMY FOR T1B RCC. Vitaly Margulis MD. Associate Professor of Urology

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1 ELECTIVE PARTIAL NEPHRECTOMY FOR T1B RCC Vitaly Margulis MD Associate Professor of Urology

2 NEPHRON SPARING SURGERY WHY? MAXIMIZING NEPHRON MASS SAVES LIVES ELECTIVE PARTIAL NEPHRECTOMY IF: TECHNICALLY FEASIBLE ONCOLOGICALLY SAFE FUNCTIONAL RENAL REMNANT IS PRESERVED

3 NEPHRON SPARING SURGERY T1B RCC WHY? LITTLE ARGUMENT REGARDING ELECTIVE NSS IN T1A TUMORS?T1B RCC OGRAN CONFNED TUMORS 4-7 CM? ONCOLOGIC OUTCOMES RENAL FUNCTION OUTCOMES AND DOWSNTREAM EFFECTS PROCEDURE RELATED MORBIDITY

4 ONCOLOGIC OUTCOMES EORTC - THE ONLY PROSPECTIVE TRIAL ALL TUMORS < 5 CM NO DIFFERENCE IN CANCER SPECIFIC OUTCOMES Van Poppel et al Eur Urol 2010

5 Thompson RH. J Urol ONCOLOGIC OUTCOMES T1B 2 institutions Retrospective T1b 1,159 patients ( ) 286 (25%) Partial nephrectomy 873 (75%) Radical nephrectomy PN RN PN RN Thompson et al J Urol 2009

6 ONCOLOGIC OUTCOMES T1B SEER DATA ALL TUMORS 4-7 CM PROPENSITY MATCH Badalato et al BJUI 2011

7 ONCOLOGIC OUTCOMES T1B -> UPSTAGED ON FINAL PATH Single institution Retrospective ( ) T2 and higher 601 patients 567 RN 34 PN Margulis et al BJUI 2007

8 Kim et al J Urol 2012 RENAL FUNCTION OUTCOMES

9 RENAL FUNCTION OUTCOMES FREEDOM FROM GFR <45 Huang et al Lancet Oncol 2006

10 RENAL FUNCTION OUTCOMES Age-Standardized Rates of Death from Any Cause (Panel A), Cardiovascular Events (Panel B) According to the Estimated GFR among 1,120,295 Ambulatory Adults Go et al NEJM 2012

11 RENAL FUNCTION OUTCOMES EORTC RANDOMIZED TRIAL OF PARTIAL VS. RADICAL NEPHRECTOMY TUMORS < 5 CM Lowest GFR (ml/min/1.73 m2) RN NSS 95% CI < % 64.7% 13.8 to 28.3 < 45 49% 27.1% 13.8 to 20.2 < 30 10% 6.3% NS < % 1.6% NS Scosyrev et al Eur Urol 2013

12 RENAL FUNCTIONAL OUTCOMES EORTC RANDOMIZED TRIAL OF PARTIAL VS. RADICAL NEPHRECTOMY TUMORS < 5 CM Scosyrev et al Eur Urol 2013

13 RENAL FUNCTION OUTCOMES Surgical vs. Medical CKD Surgical CKD vs Survival Medical CKD vs Survival Lane et al J Urol 2013

14 COMPLICATIONS EORTC RANDOMIZED TRIAL OF PARTIAL VS. RADICAL NEPHRECTOMY TUMORS < 5 CM Rate of urinary fistulae: 4.4% 3X risk of severe hemorrhage 3.1 vs. 1.2% Nearly double the need for reoperation 4.4% vs. 2.4% Van Poppel et al Eur Urol 2010

15 COMPLICATIONS NEPHROMETRY SCORE PREDICTS COMPLICATIONS AFTER PN CLAVIEN > 3 p = % % 11.1% 0 Low (NS: 4-6) Moderate (NS: 7-9) High (NS: 10-12) Simhan et al Eur Urol 2011

16 COMPLICATIONS NEPHROMETRY SCORE PREDICTS COMPLICATIONS AFTER PN SIGNIFICANT URINE LEAK % 6.0% 1.8% Low (NS: 4-6) Moderate (NS: 7-9) High (NS: 10-12) Simhan et al Eur Urol 2011

17 COMPLICATIONS NEPHROMETRY SCORE PREDICTS COMPLICATIONS AFTER PN TRANSFUSION/EMBOLIZATION Simhan et al Eur Urol % ORGAN LOSS EXCEEDINGLY RARE REOPERATIONS IN MODERN ERA UNCOMMON COMPLICATIONS MANAGED CONSERVATIELY 3.2% 3.1% 0.9% 0.0% 0.0% Low (NS: 4-6) Moderate (NS: 7-9) High (NS: 10-12)

18 ELECTIVE PARTIAL VS. RADICAL NEPHRECTOMY FOR T1B RCC ONCOLOGIC OUTCOMES Likely equivalent RENAL FUNCTION OUTCOMES PN better preservation of GFR BUT Long term clinical implications (CV, Dialysis etc?) COMPLICATIONS Higher for PN Increased for more complex/larger tumors FUNCTIONAL RENAL REMNANT USUALLY PRESERVED

19 ELECTIVE PARTIAL VS. RADICAL NEPHRECTOMY FOR T1B RCC LIMITED PROSPECTIVE BIAS-FREE DATA ELECTIVE PN APPROPRIATE TREATMENT CHOICE NEED COMPREHENSIVE CLINICAL MODELS BASED ON PATIENT AND TUMOR CHARACTERISTICS THAT CAN HELP SELECT PATIENTS WHO WILL DERIVE LONG TERM BENEFIT FROM NEPHRON SPARING

20 ELECTIVE PARTIAL NEPHRECTOMY FOR T1B RCC THANK YOU