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Year : 2011  |  Volume : 27  |  Issue : 2  |  Page : 300-301
 

Partial nephrectomy in the elderly with T1 renal tumors: Is it a viable treatment option?


Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication8-Jul-2011

Correspondence Address:
Bastab Ghosh
Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Ghosh B, Dorairajan LN, Kumar S. Partial nephrectomy in the elderly with T1 renal tumors: Is it a viable treatment option?. Indian J Urol 2011;27:300-1

How to cite this URL:
Ghosh B, Dorairajan LN, Kumar S. Partial nephrectomy in the elderly with T1 renal tumors: Is it a viable treatment option?. Indian J Urol [serial online] 2011 [cited 2019 Sep 17];27:300-1. Available from: http://www.indianjurol.com/text.asp?2011/27/2/300/82868

Lowrance WT, Yee DS, Savage C, Cronin AM, O′Brien MF, Donat SM, et al. Complication after radical and partial nephrectomy as a function of age. J Urol 2010;183:1725-30.



   Summary Top


This large retrospective study analyzed patients, who underwent nephrectomy for renal cancer between January 2000 and October 2008 at a single center, to determine whether association of age and perioperative outcomes differed between those undergoing partial nephrectomy (PN) and those undergoing radical nephrectomy (RN). [1] Patients with absolute indications for either RN or PN were excluded from the study. Those operated by general surgeons or patients with various missing data on age, estimated glomerular filtration rate (eGFR), ASA score or tumor size were also excluded leaving 1712 patients for analysis. Postoperative complications up to 90 days were considered for analysis. The statistical analysis was done creating a multivariable logistic regression model which included patient's age, eGFR, procedure type (RN or PN) and pathological tumor size (a surrogate for preoperative tumor size) as predictors. Using this model, the authors determined whether relationship between age and risk of postoperative complications, estimated blood loss (EBL) or operative time differed by nephrectomy type. Thirty-eight percent (651) of total patients (1712) underwent RN and rest 62% (1061) underwent PN. Median age of RN patients (63 years) was a little more than PN patients (61 years). The tumor size of RN group was somewhat higher than PN group (5.7 cm versus 2.8 cm). Overall 305 (18%) patients developed various complications within 90 days. Patients treated with RN had a lower complication rate than those with PN (14% versus 20%). Age was found to be significantly associated with rate of postoperative complications, both in univariate (OR for 10-year increase in age 1.16, 95% CI 1.05-1.29, P=0.005) and multivariate analysis (OR for 10-year increase in age 1.17, 95% CI 1.04-1. 32, P=0.009), regardless of procedure type. But no evidence was found that the higher risk of complications associated with PN versus RN increases with advancing age. Age affected the outcome more adversely in RN patients than PN patients. In men younger than 75 years the OR for complications for PN versus RN was 1.64 (95% CI 1.22-2.21) versus 1.12 (95% CI 0.59-2.13) for men older than 75 years. Similar findings were noted if the cut off age was set at 65 years. Three deaths were recorded in patients older than 65 years who underwent RN, but none in PN group. Although, for each group (PN or RN), there was no significant association between age and EBL or operative time, they found that the difference in operating times between the two procedure types was significantly higher (P=0.04) in the older age group. RN in older patients had shorter operative time than PN in the same age group. In the subgroup analysis of tumors up to 7 cm the findings were similar, with similar complication rates and the effect of age. Thus the authors concluded that though there is a slightly higher overall complication rate in PN as compared to RN, there was no evidence that this difference increases with advancing age. The authors conclude that as the concerns of higher complication rate, greater blood loss and longer operative time in patients undergoing PN are not related to age, elderly patients should not be denied PN only because of age.


   Comments Top


Advancing age is one of the more significant risk factors for developing renal cell carcinoma (RCC). Most cases are diagnosed in individuals with age >65 years, with the highest incidence in the age group of 75-85 years. [2] Clinicians should consider factors such as life expectancy, comorbidities and the expected morbidity of surgery while counseling for available treatment options. [3] Furthermore nephron-sparing surgery (NSS) has become an established treatment modality to preserve renal function while maintaining oncological efficacy for the management of small renal masses. Although traditionally RN has been considered the standard surgical therapy, the current AUA guidelines suggest PN as the standard of care for tumors less than 7 cm in select cases. [4] A recent study has demonstrated that RN is associated with increased cardiovascular events and chronic kidney disease as compared to PN in patients >65years. [5] In addition, PN achieves a better health-related quality of life due to better preservation of renal function and overall quality of life. [6] The results of the first randomized prospective trial also suggest that NSS for small, easily resectable RCC in the presence of a normal contralateral kidney can be performed safely with only slightly higher complication rates than RN. [7] Despite all these, the adoption of PN into general urological practice is low. The reasons may be the lesser familiarity with the technique of PN and doubts about its safety in the elderly. The current study fills up this lacuna to some extent as this is one of the largest series addressing the impact of age on the complications of PN. As in any other retrospective study this study also has some limitations like selection bias. In addition, it is not clear what proportions of surgeries were performed using open, laparoscopic and robotic techniques in the two groups. More over the study represents the experience of a high-volume tertiary care center and these results can only be generalized to the community urology practice with caution. Nevertheless, while RN has so far been the standard of care for T1 tumors in the elderly, there is much scope for extending the use of PN in properly selected elderly patients with added benefits of renal function preservation. Such elderly patients, whenever possible, must be referred to centers with substantial experience in PN.

 
   References Top

1.Lowrance WT, Yee DS, Savage C, Cronin AM, O′Brien MF, Donat SM, et al. Complication after radical and partial nephrectomy as a function of age. J Urol 2010;183:1725-30.   Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Altekruse SF, Kosary CL, Krapcho M, Neyman N, Aminou R, Waldron W, et al, editors. SEER Cancer Statistics Review, 1975-2007, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2007/, based on November 2009 SEER data submission, posted to the SEER web site, 2010.Section - Cancer of Kidney and Renal Pelvis Cancer, http://seer.cancer.gov/csr/1975_2007/results_merged/sect_11_kidney_pelvis.pdf.   Back to cited text no. 2
    
3.Thomas AA, Aron M, Hernandez AV, Lane BR, Gill IS. Laparoscopic partial nephrectomy in octogenarians. Urology 2009;74:1042-6.  Back to cited text no. 3
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4.Novick AC, Campbell SC, Belledegrun A, Blute ML, Chow GK, Derweesh IH, et al. AUA guidelines: Guideline for management of the clinical stage 1 renal mass. USA: American Urological Association Education and Research Inc; 2009. p. 1-81.  Back to cited text no. 4
    
5.Huang WC, Elkin EB, Levey AS, Jang TL, Russo P. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors: Is there a difference in mortality and cardiovascular outcomes? J Urol 2009;181:55-61.   Back to cited text no. 5
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6.Lesage K, Joniau S, Fransis K, Van Poppel H. Comparison between open partial and radical nephrectomy for renal tumors: Perioperative outcome and health-related quality of life. Eur Urol 2007;51:614-20.  Back to cited text no. 6
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7.Van Poppel H, Da Pozzo L, Albrecht W, Matveev V, Bono A, Borkowski A, et al. A prospective randomized EORCT intergroup phase 3 study comparing the complications of elective nephron sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2007;51:1606-15.  Back to cited text no. 7
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