title: Outcomes and predictors of clinical T1 to pathological T3a tumor up-staging after robotic partial nephrectomy: a multi-institutional analysis.
abstract: OBJECTIVE
  We evaluated the early oncological end point of recurrence-free survival in patients with renal cell carcinoma up-staged from cT1 to pT3a after partial nephrectomy. We also aimed to establish preoperative factors associated with pathological tumor up-staging.
  
  
  METHODS
  A prospective database of robotic partial nephrectomy cases performed at 5 academic centers was queried for patients who underwent surgery for a solitary cT1 renal mass. Patients with pT1-2 renal cell carcinoma were compared to those with pT3a tumors to determine the difference in recurrence-free survival. Preoperative factors associated with cT1 to pT3a up-staging were studied using multivariate logistic regression analysis.
  
  
  RESULTS
  A total of 1,096 patients underwent robotic partial nephrectomy for a cT1 renal mass. At final pathological evaluation 855 tumors (78.0%) were found to be renal cell carcinoma, of which 41 (4.8%) were up-staged to pT3a. The 24-month recurrence-free survival estimates for pT1-2 and pT3a tumors were 99.2% and 91.8%, respectively (p=0.003). Multivariate analysis revealed that a high vs low R.E.N.A.L. (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior and location relative to polar lines) nephrometry score was associated with tumor up-staging (OR 2.97, 95% CI 1.20-7.35, p=0.02). On separate multivariate analysis increasing tumor diameter (OR 1.66, 95% CI 1.32-2.08, p<0.001) and hilar location (OR 2.83, 95% CI 1.43-5.61, p=0.003) were also associated with up-staging.
  
  
  CONCLUSIONS
  At short-term followup patients with renal cell carcinoma up-staged from cT1 to pT3a have reasonable oncological outcomes after partial nephrectomy. Factors associated with tumor up-staging include high tumor complexity, increasing tumor diameter and hilar location. Further studies are needed to determine the comparative efficacy of partial vs radical nephrectomy for small pT3a tumors.
authors.affiliation: The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, Maryland. Electronic address: mgorin1@jhmi.edu.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Gorin
authors.forename: Mark W
authors.initials: MW
authors.lastname: Ball
authors.forename: Phillip M
authors.initials: PM
authors.lastname: Pierorazio
authors.forename: Youssef S
authors.initials: YS
authors.lastname: Tanagho
authors.forename: Sam B
authors.initials: SB
authors.lastname: Bhayani
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
authors.forename: Craig G
authors.initials: CG
authors.lastname: Rogers
authors.forename: Michael D
authors.initials: MD
authors.lastname: Stifelman
authors.forename: Ali
authors.initials: A
authors.lastname: Khalifeh
authors.forename: Ramesh
authors.initials: R
authors.lastname: Kumar
authors.forename: Ganesh
authors.initials: G
authors.lastname: Sivarajan
authors.forename: Mohamad E
authors.initials: ME
authors.lastname: Allaf
mesh_terms: D000368:Aged; D002292:Carcinoma, Renal Cell / Q000473:pathology / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000379:methods*; D011379:Prognosis; D011446:Prospective Studies; D012371:Robotics; D016896:Treatment Outcome
keywords: PN; RCC; RN; carcinoma; kidney; neoplasm staging; nephrectomy; partial nephrectomy; radical nephrectomy; renal cell; renal cell carcinoma; robotics