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Surgical Management of Renal Cell Carcinoma in Patients ≥80 Years Old Using the National Surgical Quality Improvement Program (NSQIP) Database
Casey Kowalik, MD, John A. Libertino, MD, Jason Gee, MD, Andrea Sorcini, MD, Alireza Moinzadeh, MD, David Canes, MD.
Lahey Hospital & Medical Center, Burlington, MA, USA.
Background: Surgical decision making for renal cell carcinoma (RCC) in octogenarians is a complex balance, weighing existing comorbidities, the need for renal preservation, and potential perioperative morbidity. Radical nephrectomy is often preferred to partial nephrectomy over concerns for surgical complications, presumed to be lower with radical nephrectomy, however data is lacking in this regard. We investigated complications of partial or radical nephrectomy for the management of RCC in patients ≥80 years old.
Methods: Using the National Surgical Quality Improvement Program (NSQIP) 2005-2011 data files, patients with RCC were identified by ICD-9 code 189. We analyzed procedure type, length of hospitalization, and complications, which were categorized according to the Clavien system. Nephrometry score could not be determined, since tumor characteristics are not recorded in this database.
Results: We identified 4,175 patients undergoing partial (n=1,525) or radical (n=2,650) nephrectomy for RCC, of which 310 (7.4%) were ≥80 years old. Average hospitalization was longer for the older group (6.8 v 4.5 days, p=0.0001). Only 17.7% of elderly patients underwent partial nephrectomy compared to 51.3% in the <80 year old group. Clavien complications are listed in Table 1. Taking all procedures together, patients ≥80 years old had significantly more complications than the younger group (49% v 26%, p=0.0001). On sub-analysis, there were also more Clavien 4/5 complications in the older group (12.3% v 5.4%, p=0.0001). Additionally, 5.5% of patients ≥80, compared to 2.6% of patients <80, returned to the operating room (Clavien 3) (p=0.003). In the ≥80 group, the complication rates between partial and radical nephrectomy were statistically equivalent (p=0.13). However, both radical nephrectomy (p=0.0001) and partial nephrectomy (p=0.0001) are associated with more complications in patients ≥80 compared with those <80 years old.
Conclusions: Surgical management of RCC in patients ≥80 years old is associated with higher overall complication rates than patients <80 and major (Clavien 4/5) complication rates are doubled. Patients ≥80 years old are more likely to undergo radical than partial nephrectomy, however in this age group there is no discernible difference in complication rates between partial and radical nephrectomy. Thus, if the tumor is amenable and surgery is indicated, partial nephrectomy should be considered in patients ≥80 years old. We acknowledge limitations such that outcomes could not be adjusted for tumor size/complexity and no survival data is given.
|Table 1. Comparison of complications by age and procedure type|
|<80 years old (n=3,865)||≥80 years old (n=310)|
|RN (n=2,395)||PN (n=1,470)||RN (n=255)||PN (n=55)|
|Clavien 1||30 (1.3%)||14 (1.05%)||4 (1.6%)||0 (0%)|
|Clavien 2||460 (19.2%)||191 (13.0%)||72 (28.2%)||21 (38.2%)|
|Clavien 3||67 (2.8%)||33 (2.2%)||14 (5.5%)||3 (5.5%)|
|Clavien 4||139 (5.8%)||46 (3.1%)||26 (10.2%)||6 (10.9%)|
|Clavien 5||23 (1.0%)||3 (0.2%)||4 (1.6%)||2 (3.6%)|
|Total||719 (30%)||287 (19.5%)||120 (47%)||32 (58.2%)|
|RN= radical nephrectomy, PN = partial nephrectomy|
Disclosure: The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
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