Trifecta Outcomes of Partial Nephrectomy in Patients Over 75 Years Old: Analysis of the REnal SURGery in Elderly (RESURGE) Group

Ahmet Bindayi, Riccardo Autorino, Umberto Capitanio, Nicola Pavan, Maria Carmen Mir, Alessandro Antonelli, Toshio Takagi, Riccardo Bertolo, Tobias Maurer, Koon Ho Rha, Jean Alexandre Long, Bo Yang, Luigi Schips, Estevão Lima, Alberto Breda, Estefania Linares, Antonio Celia, Cosimo De Nunzio, Ryan Dobbs, Sunil PatelZachary Hamilton, Andrew Tracey, Alessandro Larcher, Carlo Trombetta, Carlotta Palumbo, Kazunari Tanabe, Thomas Amiel, Ali Raheem, Gaelle Fiard, Chao Zhang, Roberto Castellucci, Joan Palou, Stephen Ryan, Simone Crivellaro, Francesco Montorsi, Francesco Porpiglia, Ithaar H. Derweesh

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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. Partial nephrectomy in elderly patients provides quality outcomes as measured by trifecta. Tumor complexity is a key determinant for trifecta achievement, and trifecta attainment is associated with improved function. Increasing utilization of robotics has benefits in recovery without compromising quality.

Original languageEnglish
JournalEuropean Urology Focus
DOIs
Publication statusAccepted/In press - 2019 Jan 1

All Science Journal Classification (ASJC) codes

  • Urology

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    Bindayi, A., Autorino, R., Capitanio, U., Pavan, N., Mir, M. C., Antonelli, A., Takagi, T., Bertolo, R., Maurer, T., Ho Rha, K., Long, J. A., Yang, B., Schips, L., Lima, E., Breda, A., Linares, E., Celia, A., De Nunzio, C., Dobbs, R., ... Derweesh, I. H. (Accepted/In press). Trifecta Outcomes of Partial Nephrectomy in Patients Over 75 Years Old: Analysis of the REnal SURGery in Elderly (RESURGE) Group. European Urology Focus. https://doi.org/10.1016/j.euf.2019.02.010