Larcher A., Fossati N., Tian Z., Boehm K., Meskawi M., Valdivieso R., Trudeau V., Dell’Oglio P., Buffi N., Montorsi F., Guazzoni G., Sun M., Karakiewicz P.I.
European Urology 2015
Background: Current guidelines recommend local tumour ablation (LTA) over partial nephrectomy (PN) in nonsurgical candidates; however, objective definitions of these candidates are lacking. Objective: To identify specific patients who would benefit from LTA more than PN. Design, setting, and participants: A population-based assessment was performed of 2476 patients in the Surveillance Epidemiology and End Results-Medicare database who had cT1a kidney cancer treated with either LTA or PN, between 2000 and 2009. Outcome measurements and statistical analysis: The outcome of the study was the relevant perioperative complications rate. A multivariable logistic regression model was fitted to predict the risk of complications after PN. Model-derived coefficients were used to calculate the risk of complication in case of PN among patients treated with LTA. Locally weighted scatterplot smoothing method was used to plot the observed complication rate against the predicted risk of complication in case of PN. Results and limitations: At multivariable logistic regression, age (odds ratio [OR]: 1.04; p <. 0.001), Charlson comorbidity index (OR: 1.14; p <. 0.001), acute kidney injury (OR: 1.91; p = 0.04), or chronic kidney disease (OR: 2.16; p = 0.002), tumour size (OR: 1.02; p = 0.01), and minimally invasive approach (OR: 0.77; p <. 0.03) emerged as significant predictors of complications. When LTA was chosen over PN, the reduction in the risk of complications was greatest in high-risk patients, intermediate in intermediate-risk patients, and least in low-risk patients. Conclusions: When postoperative complications are evaluated, the benefit of choosing LTA is not the same in all patients diagnosed with T1a kidney cancer. Specifically, patients at high risk of complications in case of PN may benefit the most from LTA and represent ideal LTA candidates. Patient summary: Elderly patients at high risk of complications in case of surgical treatment with partial nephrectomy for kidney cancer should be instructed that local tumour ablation might decrease their perioperative morbidity. Elderly patients at high risk of complications in case of surgical treatment with partial nephrectomy for cT1a kidney cancer might represent ideal candidates for local tumour ablation, since this option decrease their perioperative morbidity.