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Partial Nephrectomy in Solitary Kidneys: Intraoperative Techniques and Their Impact on Chronic Kidney Disease
Benjamin N Schmeusser1, Courtney Yong1, Daniel Sidhom1
1Department of Urology, School of Medicine, Indiana University, 535 Barnhill Drive|RT 150, Indianapolis, IN 46202, USA.
Objective:
Solitary kidney tumors are a challenging scenario necessitating both oncologic efficacy and renal function preservation. Partial nephrectomy (PN), when feasible, remains the gold standard for management. We examine intraoperative techniques and their association with renal function decline in patients with solitary kidneys undergoing PN.
Methods:
In two high volume academic referral centers, we analyzed patients that underwent PN in a solitary kidney from 2000 to 2023. Patient characteristics, tumor details, and operative details were obtained. Chronic kidney disease (CKD) upstaging from pre- to postoperative was the primary outcome, with multivariable analysis examining the association between intraoperative factors and CKD progression.
Results:
In total, 104 patients were included, of which 38 (36.5%) experienced CKD upstaging. Mean eGFR decline was 15.4% at median follow-up of 16 months. Cold ischemia was associated with higher odds of CKD upstaging compared to warm ischemia (OR 3.64; 95% CI 1.06-12.52) and no ischemia (4.55; 95% CI 1.09). Notably, cold ischemia cases tended to involve significantly larger, more complex tumors in patients with lower baseline renal function. Ischemia time, parenchyma resection, renal volume change, operative time, and renorrhaphy type were not predictors of CKD upstaging.
Conclusions:
PN in solitary kidneys remains standard with evidence of excellent renal preservation in this cohort. Worse outcomes were observed with cold ischemia, although this more likely represents underlying tumor complexity with other uncontrollable factors; however, this should be explored further. These findings suggest that renal functional outcomes are likely reasonable in patients with solitary kidneys undergoing PN when appropriate patient selection and sound surgical technique are utilized.
Insights
Partial nephrectomy (PN) for solitary kidney tumors preserves renal function. Cold ischemia was linked to worse outcomes, possibly due to complex tumors, but overall results are good with proper patient selection.
Area of Science:
- Urology
- Nephrology
- Surgical Oncology
Background:
- Solitary kidney tumors present a management challenge, balancing cancer control with kidney function preservation.
- Partial nephrectomy (PN) is the preferred surgical approach for amenable solitary kidney tumors.
- Intraoperative techniques during PN can impact postoperative renal function.
Purpose of the Study:
- To investigate the association between intraoperative techniques and renal function decline in patients with solitary kidneys undergoing PN.
- To identify factors influencing chronic kidney disease (CKD) upstaging after PN in solitary kidneys.
Main Methods:
- Analysis of 104 patients who underwent PN for a solitary kidney between 2000 and 2023 at two academic centers.
- Evaluation of patient characteristics, tumor details, and operative data.
- Multivariable analysis to determine the impact of intraoperative factors on CKD upstaging (pre- to postoperative).
Main Results:
- 36.5% of patients experienced CKD upstaging, with a mean estimated glomerular filtration rate (eGFR) decline of 15.4% at 16 months.
- Cold ischemia was associated with significantly higher odds of CKD upstaging compared to warm ischemia or no ischemia.
- Tumor size, complexity, and baseline renal function were notable in cold ischemia cases; ischemia time and other surgical factors were not predictors of CKD upstaging.
Conclusions:
- PN in solitary kidneys demonstrates good renal preservation, with CKD upstaging observed in 36.5% of cases.
- Cold ischemia may be associated with worse renal outcomes, potentially reflecting underlying tumor complexity.
- Appropriate patient selection and surgical technique are crucial for optimizing renal functional outcomes in solitary kidney PN.
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