Impact of Positive Surgical Margins After Partial Nephrectomy

Abstract

Background The impact of positive surgical margins (PSMs) after partial nephrectomy (PN) is controversial. Objective To evaluate the risk factors for a PSM and its impact on overall survival. Design, setting, and participants This is a retrospective study of 388 patients were submitted to PN between November 2005 and December 2016 in a single centre. Two groups were created: PSM and negative surgical margin (NSM) after PN. A p value of <0.05 was considered significant. Outcome measurements and statistical analysis Relationships with outcome were assessed using univariable and multivariable tests and log-rank analysis. Results and limitations The PSM rate was 3.8% ( N = 16). The mean age at the time of surgery (PSM group: 64.1 ± 11.3 vs NSM group: 61.8 ± 12.8 yr, p = 0.5) and the mean radiological tumour size (4.0 ± 1.5 vs 3.4 ± 1.8 cm, p = 0.2) were similar. Lesion location ( p = 0.3), surgical approach ( p = 0.4), warm ischaemia time ( p = 0.9), and surgery time ( p = 0.06) had no association with PSM. However, higher surgeon experience was associated with a lower PSM incidence (2.6% if ≥30 PNs vs 9.6% if <30 PNs; p = 0.02). Higher operative blood loss ( p = 0.02), higher-risk tumours ( p = 0.03), and larger pathological size ( p = 0.05) were associated with an increase in PSM. In the PSM group, recurrence rate (18.7% vs 4.2%, p = 0.007) and secondary total nephrectomy rate (25% vs 4.4%, p < 0.001) were higher. However, overall survival was similar. Multivariate analysis revealed that high-risk tumour ( p = 0.05) and low experience ( p = 0.03) could predict a PSM. Limitations include retrospective design and reduced follow-up time. Conclusions PSMs were mainly associated with high-risk pathological tumour ( p = 0.05) and low-volume surgeon experience. Recurrence rate and need for total nephrectomy were higher in that group, but no impact on survival was noticed. Patient summary The impact of positive surgical margins (PSMs) after partial nephrectomy is a matter of debate. In this study, we found that PSMs were mainly associated with aggressive disease and low surgeon experience.

Comparison of prognosis between patients undergoing radical nephrectomy versus partial nephrectomy for renal cell carcinoma ≤7 cm T3aN0/xM0: Survival benefit is biased toward partial nephrectomy

“…But because of the application of robot-assisted PN, the preoperative evaluation of imaging three-dimensional imaging technology, and the increased experience of the surgeon, the warm ischemia time is shortened compared with the past, which may not affect the postoperative renal function. 3,31,38,39 In complex RCC, to achieve trifecta after PN, surgical technique plays an important role. 40 Previous studies have reported that surgical technique is an independent predictor of trifecta outcome.…”

“…42 For T3a RCC, the incidence of positive surgical margins for PN is higher, with an average of about 18%. 31 Although the impact of positive surgical margins after PN on the prognosis is a matter of debate, some prior studies observed positive surgical margins were significantly associated with aggressive disease characteristics and low surgeon experience, 38 but not significantly impact the short-term survival functions. 38,43 Our study had some unavoidable limitations.…”

“…31 Although the impact of positive surgical margins after PN on the prognosis is a matter of debate, some prior studies observed positive surgical margins were significantly associated with aggressive disease characteristics and low surgeon experience, 38 but not significantly impact the short-term survival functions. 38,43 Our study had some unavoidable limitations. Although the SEER database has the advantages of its large sample size, it also has some drawbacks, including the inherent limitation of its retrospective nature.…”

Positive surgical margin’s impact on short-term oncological prognosis after robot-assisted partial nephrectomy (MARGINS study: UroCCR no 96)

“…The majority of studies reported so far have indicated that positive surgical margins do not correlate with a higher risk of metastases or decreased cancer specific survival (CSS) 8 , 9 . On the other hand, large retrospective studies showed that PSM, are an independent predictor of recurrence 10 , 11 . Absence of PSM, such as in Trifecta 12 achievement, has also shown a predictive role on long term outcomes after RAPN 13 .…”

Surgical Video Review of Warm Ischemia Time during Laparoscopic Partial Nephrectomy and Impact on Positive Surgical Margins and Postoperative Complications

“…However, these approaches are technically challenging and are associated with a high rate of complications reported in up to 30% of cases [2]. Another concern is the positive surgical margins (PSM) reported in up to 4% of cases [3].…”