Five to 10-Year Followup of Open Partial Nephrectomy in a

Solitary Kidney
Christina B. Ching, Brian R. Lane, Steven C. Campbell, Jianbo Li and
Amr F. Fergany*
From the Vanderbilt University (CBC), Nashville, Tennessee, Spectrum Health Hospital System (BRL), Grand Rapids, Michigan, and Glickman
Urological and Kidney Institute (SCC, AFF) and Quantitative Health Sciences (JL), Cleveland Clinic Foundation, Cleveland, Ohio

Abbreviations Purpose: Followup is limited in patients with a solitary kidney who undergo
and Acronyms partial nephrectomy. We evaluated overall, cancer specific and recurrence-free
CKD ⫽ chronic kidney disease survival, and renal function in patients 5 years or greater after open partial
nephrectomy.
CSS ⫽ cancer specific survival
Materials and Methods: We retrospectively reviewed the Cleveland Clinic kid-
eGFR ⫽ estimated GFR ney cancer database, including only patients with a solitary kidney treated with
EMR ⫽ electronic medical record open partial nephrectomy 5 or more years ago (from 1980 to June 2006) who had
GFR ⫽ glomerular filtration rate 6 months or more of followup. Survival and recurrence analyses were calculated
OPN ⫽ open partial nephrectomy using a Cox proportional hazards model. Results are shown as Kaplan-Meier
OS ⫽ overall survival survival curves. Linear regression analysis was done to assess postoperative
renal function.
RFS ⫽ recurrence-free survival
Results: A total of 282 patients fit our study inclusion criteria (mean followup
175 months), of whom 233 underwent open partial nephrectomy 10 or more years
Accepted for publication March 5, 2013.
ago. Actual overall survival was 78.5% and 59.5% at 5 and 10 years, respectively.
Study received institutional review board ap-
proval. The average estimated glomerular filtration rate at 5 years or greater and 10
* Correspondence: Glickman Urological and years or greater since open partial nephrectomy was 35.1 and 34.5 ml/minute/
Kidney Institute, Cleveland Clinic Foundation,
1.73 m2 in 89.7% and 89.6%, respectively, of patients with stage 3 or greater
9500 Euclid Ave. Q10, Cleveland, Ohio 44195
(telephone: 216-444-0414; FAX: 216-445-2267; chronic kidney disease. Eight survivors were on intermittent hemodialysis 5
e-mail: [email protected]). years or more postoperatively, including 5 at 10 years or more. There were 76
recurrences for a calculated 5 and 10-year recurrence-free survival rate of 72%
(95% CI 66 – 879) and 63% (95% CI 57–71), respectively.
Conclusions: Open partial nephrectomy in the solitary kidney provides reliable
long-term oncological control at 5 and 10 years. Predicted and actual outcomes
correspond well. Although most patients have chronic kidney disease postoper-
atively, it appears stable with minimal progression to dialysis.

Key Words: kidney; abnormalities; carcinoma, renal cell;

mortality; nephrectomy

PARTIAL nephrectomy provides renal patient population provides the

function outcomes superior to those unique ability to study the func-
of radical nephrectomy.1–3 Consider- tional aspects of partial nephrec-
ation for partial nephrectomy is espe- tomy given the lack of a normally
cially important in patients with a compensating contralateral kidney.
functionally solitary kidney since rad- We previously evaluated renal
ical nephrectomy would render them function in 400 patients with a func-
anephric, necessitating dialysis.4 This tionally solitary kidney treated with

0022-5347/13/1902-0470/0 http://dx.doi.org/10.1016/j.juro.2013.03.028
THE JOURNAL OF UROLOGY® Vol. 190, 470-474, August 2013
470 www.jurology.com
© 2013 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. Printed in U.S.A.
 FIVE TO 10-YEAR FOLLOWUP OF OPEN PARTIAL NEPHRECTOMY IN A SOLITARY KIDNEY 471

partial nephrectomy for a renal tumor with a mean RESULTS

followup of 44 months.5 Renal function remained A total of 282 patients who fulfilled our long-term
satisfactory in 95.5% of patients and renal failure followup criteria were treated with partial nephrec-
developed in only 18 (4.5%) a mean of 3.6 years after tomy in a functionally and/or anatomically solitary
surgery. Projected 5 and 10-year CSS was 89% and kidney at our institution between 1980 and June
82%, and OS was 87% and 77%, respectively. The 2006. The individual decision for surgery was incom-
local recurrence rate was 10% with local plus distant pletely documented and likely based on surgeon
recurrence in 6.5% of cases. preference. The supplementary table (http://jurology.
We now present updated and longer-term fol- com/) shows patient characteristics before and at
lowup in our patients with a solitary kidney treated surgery. Of the patients 211 had a solitary kidney
with OPN. We evaluated actual 5 and 10-year renal due to prior nephrectomy, including 88.2% for pre-
function, and oncological outcomes to provide fur- vious malignancy. Median time between asynchro-
ther insight into this special patient population. nous tumors was 3 years (range 0 to 49). Mean
followup in all 282 patients was 175 months and 233
underwent OPN 10 years or more ago.
MATERIALS AND METHODS Based on the Kaplan-Meier curve, predicted
5-year OS was 80% (95% CI 75– 85) and at 10 years
Patients in a solitary kidney database who had a function-
ally or anatomically solitary kidney and were treated with predicted survival was 58% (95% CI 52– 65) (fig. 1).
OPN for a presumed malignant renal mass more than 5 Actual OS using our data was 78.5% at 5 years and
years previously (from 1980 to June 2006) at Cleveland 59.5% at 10 years. Median time from partial ne-
Clinic were included in analysis after we obtained insti- phrectomy to death was 9.6 years (mean 9.7). On
tutional review board approval. A minimum of 6 months of multivariate analysis age at partial nephrectomy
followup was required for inclusion. Patients with familial (p ⱕ0.0001) and malignant pathology (p ⫽ 0.0107)
forms of renal tumors were excluded. All operations were were significantly related to OS. Comorbidities such
performed using a previously described in situ surgical as hypertension, diabetes and coronary artery dis-
technique with 91% done by a single surgeon.6,7 ease were not related to OS (table 1).
The EMR was used to update our database as appro- Calculated RFS at 5 years was 72% (95% CI 66 –
priate to evaluate the most recent renal function, need for 79) and 63% (95% CI 57–71) at 10 years with 76
dialysis or kidney transplantation, pertinent imaging for documented recurrences (27.0%) (fig. 2, A). Actual 5
recurrence, referrals to medical oncology and treatment
and 10-year RFS using our data was 75.4% and
for recurrence. Only information that could be obtained
70.8%, respectively. Time to recurrence was 45 days
from the EMR was used for analysis, including followup at
to 26.1 years (median 3.6 years). No variable, ie
our institution or according to records from other hospitals
documented in our EMR. Renal function status was eval- tumor stage T2 or greater (p ⫽ 0.1937), lymphovas-
uated using the eGFR, as calculated by the Modification of cular invasion (p ⫽ 0.1576), prior nephrectomy for
Diet in Renal Disease 2 equation.8 CKD was staged ac- malignancy (p ⫽ 0.5685) or a positive surgical mar-
cording to the National Kidney Foundation Dialysis Out-
comes Quality Initiative Clinical Practice Guidelines.9 Pa-
tient followup varied based on the staff following the
patient and on final pathological results.
We also evaluated 5 and 10-year survival and oncolog-
ical outcomes, specifically looking for OS, RFS and CSS.
Recurrence was defined as radiologically verified local re-
currence, or progression to nodal or metastatic disease.
We cross-checked our mortality information using the
Social Security Death Index online database (http://ssdi.
rootsweb.com/, last updated June 22, 2011).
Statistical analysis was done at the Department of
Quantitative Health Sciences, Cleveland Clinic using R,
version 2.14 (http://www.r-project.org) and its rms pack-
age. Data are shown as the mean and SD, median and IQR
or count or frequency with the percent or proportion. Sur-
vival and recurrence analysis was calculated using a Cox
proportional hazards model considering covariates such as
age, gender, race, preoperative renal function and kidney
status. Linear regression analysis was done to assess post-
operative renal function using similar covariates. Kaplan-
Figure 1. Kaplan-Meier curve of predicted OS 5 and 10 years
Meier survival curves were generated with bands of 95%
after OPN.
CIs. Statistical significance was considered at ␣ ⫽ 0.05.
472 FIVE TO 10-YEAR FOLLOWUP OF OPEN PARTIAL NEPHRECTOMY IN A SOLITARY KIDNEY

Table 1. Multivariate overall survival predictors Table 2. Univariate predictors of renal function change

HR p Value p Value

Age 2.43 ⬍0.0001 Charlson comorbidity index 0.0242

Pathological Ca findings 1.89 0.0107 Hypertension 0.0322
Male gender 1.04 0.2092 Preop eGFR ⬍0.0001
Race 1.36 0.1719 Tumor size:
Preop eGFR 0.80 0.0513 Clinical 0.0277
Hypertension 0.73 0.5746 Pathological 0.0041
Diabetes 1.75 0.1590 T stage 0.0013
Coronary artery disease 1.39 0.4198 Recurrence 0.0470
Prior nephrectomy for malignancy 0.77 0.7281 % Spared renal parenchyma ⬍0.0500

gin (p ⫽ 0.8146), demonstrated a significant associ- erative eGFR were significantly associated with can-
ation with recurrence. cer specific mortality (p ⱕ0.0001 and 0.0030, respec-
Of the patients 26 died of renal cancer at a me- tively). Prior nephrectomy for malignancy did not
dian of 4.5 years (range 0.4 to 12.3). Estimated CSS significantly predict cancer specific death (p ⫽ 0.0553).
at 5 and 10 years was 96% (95% CI 94 –99) and 94% Given that 87.1% of patients with known patho-
(95% CI 91–98), respectively (fig. 2, B). Actual CSS logical stage had less than pathological stage T2
was 95.1% at 5 years, 91.9% at 10 years and 90.8% disease, we performed subset analysis of those with
at more than 10 years. Recurrence and lower preop- pathological stage T2 or greater. Only 3 patients
were between 5 and 10 years from surgery. All oth-
ers were greater than 10 years from surgery. When
considering only those with pathological stage T2 or
greater, OS and RFS decreased to 36.1% and 50%,
respectively, while CSS remained relatively stable
at 86.1%.
In patients 5 years or more from OPN average
eGFR at last followup was 35.1 ml/minute/1.73 m2
(median 32.4, range 3.2 to 107.3) with CKD stage 3
or greater in 89.7%. Of those 10 years or more from
OPN the average eGFR was 34.5 ml/minute/1.73 m2
(median 31.35, range 3.2 to 107.3) with CKD stage 3
or greater in 89.6%. A total of 25 patients (8.9%)
were treated with dialysis at least once postopera-
tively or underwent renal transplantation and 17
(6.0%) required permanent dialysis or underwent
transplantation. Eight survivors 5 years or more
from surgery were on intermittent hemodialysis, of
whom 5 were 10 years or more from surgery. Median
preoperative eGFR in the 17 patients treated with
permanent dialysis or transplantation was 26.1 ml/
minute/1.73 m2 (mean 28.2, range 7.2 to 55.7). This
significantly differed from that in patients who did
not proceed to permanent dialysis or transplanta-
tion (median 46.7 ml/minute/1.73 m2, mean 49.7,
p ⬍0.0001).
Table 2 lists variables associated with a greater
change in eGFR preoperatively and postopera-
tively. On multivariate analysis the determinants of
change in renal function were age at partial ne-
phrectomy (p ⱕ0.0001), tumor size (p ⫽ 0.005), pre-
operative eGFR (⬍0.0001) and percent of spared
renal parenchyma (p ⫽ 0.008). Using cold or warm
ischemia was not related to a change in eGFR on
Figure 2. Kaplan-Meier curves of survival 5 and 10 years after
univariate or multivariate analysis (p ⫽ 0.4092 and
OPN. A, calculated RFS. B, CSS.
0.6725, respectively).
 FIVE TO 10-YEAR FOLLOWUP OF OPEN PARTIAL NEPHRECTOMY IN A SOLITARY KIDNEY 473

DISCUSSION Recent interest has focused on whether the sur-

The goals of partial nephrectomy for presumed ma- gical approach (open vs laparoscopic) is a determi-
lignancy are to provide adequate cancer control, nate of long-term renal function. Lane et al found
while preserving renal function. The literature on that laparoscopic partial nephrectomy in a solitary
partial nephrectomy outcomes in patients with a kidney resulted in a significantly higher rate of
solitary kidney describes how well this has been acute dialysis postoperatively (p ⫽ 0.01), a warm
accomplished in this special population, although ischemia time of up to 9 minutes longer (p ⬍0.0001)
followup has generally been less than 5 years.10 –13 and a 2.54 times higher risk of postoperative com-
The longest followup in the literature is 5.4 years in plications (p ⬍0.05) compared to OPN.23 Although
a 1984 study by Topley et al in only 23 patients.14 To this suggests that OPN may possibly be best suited
our knowledge we present the longest followup of for this high risk patient group, increasing experi-
partial nephrectomy in a solitary kidney in a large ence with minimally invasive techniques and robot-
cohort. Given that most prior studies of 5 and 10- ics will minimize the importance of the surgical ap-
year outcomes were based on calculated projections, proach except in the most technically demanding
situations for which longer cold ischemia time is
our data are unique since we present actuarial fol-
required.
lowup.
Cancer control is the primary objective of partial
CKD is associated with increased morbidity and
nephrectomy. Thus, it is important to evaluate on-
mortality.15,16 It is an undesirable outcome after
cological outcomes in the solitary kidney population,
partial nephrectomy. The renal dysfunction rate af-
in which there are dueling interests to preserve as
ter partial nephrectomy in a solitary kidney can be
much normal parenchyma as possible while remov-
as high as 26% at a mean followup of 42 months10
ing the entire tumor. The overall recurrence rate in
with 3.7% to 6.7% of patients proceeding to end
this population was reported to be as high as 26%14
stage renal disease requiring dialysis.11,17–19 Al-
with a local recurrence rate of 11% to 19% and a
though a significant number of our patients had
metastatic recurrence rate of 5% at a median fol-
stage 3 or greater CKD at 5 and 10 years of followup,
lowup of 14.7 to 42 months.10,19,24 We similarly re-
77% had stage 3 or greater CKD even before sur-
port a relatively high 27% recurrence rate. In prior
gery. The number of our patients requiring dialysis studies local recurrence was significantly associated
echoes those in shorter studies, suggesting that af- with positive margins and greater than stage T2
ter the initial decrease due to surgical resection, disease (p ⫽ 0.01 and 0.02, respectively).19 However,
renal function remains relatively stable. we found no predictor of recurrence in our analysis.
Factors that influence renal function after part- The fact that 186 of our study patients had a solitary
ial nephrectomy in a solitary kidney include tumor kidney due to prior nephrectomy for malignancy
size, patient age, preoperative GFR and ischemia may account for our high recurrence rate. Calcu-
time.13,20 Most groups found that renal ischemia lated 5-year RFS was 72%, while our actual 5-year
time through hilar clamping negatively affects soli- RFS was 75.4%, higher than the previously reported
tary kidney function postoperatively.12,21 Patients 45.7%.24 Our RFS demonstrated relatively good du-
who underwent warm ischemia vs no ischemia were rability at 10 years with 63% predicted and 70.8%
more likely to experience acute renal failure and actual RFS. Median time from nephrectomy to re-
new onset CKD stage 4 during a mean followup of currence was 3.6 years, showing that recurrence
3.3 years.21 Other groups noted that ischemia time most commonly develops within 5 years and explain-
lost significance when the amount of parenchyma ing our observed durability of between 5 and 10
spared was incorporated in multivariate analysis.13 years.
However, the amount of parenchyma lost in patients Predicted 5 year OS was previously reported to be
with a solitary kidney who underwent partial ne- between 59.6% and 74.7%17,24,25 with 45.8% 10-year
phrectomy correlated best with renal function 2 to 6 survival.25 Our findings are significantly higher
months postoperatively vs immediately postopera- than those predicted by the Kaplan-Meier curve, as
tively (p ⫽ 0.03).22 Most recently, Lane at el found are our actual OS rates (80% and 78.5% at 5 years,
that ultimate renal function after partial nephrec- and 58% and 59.5%, respectively). Overall, we saw a
tomy in a solitary functioning kidney was not inde- relatively good correlation of predicted and actual
pendently determined by ischemia time but rather values.
by the percent of spared parenchyma and preopera- An important outcome is that radical nephrec-
tive GFR.13 We similarly found that the percent of tomy for a renal mass does not result in an ending
spared renal parenchyma and preoperative eGFR but creates a scenario, such as we describe, of a
were significant factors for ultimate renal function potential asynchronous lesion in the now solitary
along with tumor size, while ischemia type had no kidney, resulting in the potential issues addressed
impact. in our study. This reinforces the importance of care-
474 FIVE TO 10-YEAR FOLLOWUP OF OPEN PARTIAL NEPHRECTOMY IN A SOLITARY KIDNEY

ful use of nephrectomy to avoid the dilemma of a ported. Notably, although malignancy at original
renal tumor in a solidary kidney. Once a patient has nephrectomy, which left some of our patients with a
a solitary kidney, partial nephrectomy should be solitary kidney, did not influence OS, CSS or RFS,
done selectively with consideration of active surveil- this could be due to the significant number of pa-
lance for small tumors, especially in elderly patients tients in our population treated with prior nephrec-
or those with significant comorbidities who may not tomy for malignancy.
tolerate partial nephrectomy.
The main limitation of this study is its retrospec-
tive nature and selection bias. Most operations were
CONCLUSIONS
performed by a single surgeon specializing in partial
nephrectomy to whom higher complexity cases were A renal mass in a solitary kidney is a difficult clin-
referred. Our results also rely on complete documen- ical dilemma. While our results demonstrate that
tation and followup, of which much was done at the OPN in a solitary kidney blends stable, satisfactory
referring institutions. Recurrence may not be fully renal function outcome with good oncological control
documented in our EMR if patients were only fol- even at 5 and 10 years postoperatively, we stress the
lowed at referring institutions. This could explain importance of attempting to avoid rendering a pa-
our RFS rate, which is higher than previously re- tient with a solitary kidney anephric.

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