Trifecta Outcomes of Partial Nephrectomy in Patients Over 75 Years Old: Analysis of the REnal SURGery in Elderly (RESURGE) Group

Abstract

Background: Partial nephrectomy (PN) in elderly patients is underutilized with concerns regarding risk of complications and potential for poor outcomes. Objective: To evaluate quality and functional outcomes of PN in patients >75 yr using trifecta as a composite outcome of surgical quality. Design, setting, and participants: Multicenter retrospective analysis of 653 patients aged >75 yr who underwent PN (REnal SURGery in Elderly [RESURGE] Group). Intervention: PN. Outcome measurements and statistical analysis: Primary outcome was achievement of trifecta (negative margin, no major [Clavien ≥3] urological complications, and ≥90% estimated glomerular filtration rate [eGFR] recovery). Secondary outcomes included chronic kidney disease (CKD) stage III and CKD upstaging. Multivariable analysis (MVA) was used to assess variables for achieving trifecta and functional outcomes. Kaplan-Meier survival analysis (KMA) was used to calculate renal functional outcomes. Results and limitations: We analyzed 653 patients (mean age 78.4 yr, median follow-up 33 mo; 382 open, 157 laparoscopic, and 114 robotic). Trifecta rate was 40.4% (n = 264). Trifecta patients had less transfusion (p < 0.001), lower intraoperative (5.3% vs 27%, p < 0.001) and postoperative (25.4% vs 37.8%, p = 0.001) complications, shorter hospital stay (p = 0.045), and lower ΔeGFR (p < 0.001). MVA for predictive factors for trifecta revealed decreasing RENAL nephrometry score (odds ratio [OR] 1.26, 95% confidence interval 1.07–1.51, p = 0.007) as being associated with increased likelihood to achieve trifecta. Achievement of trifecta was associated with decreased risk of CKD upstaging (OR 0.47, 95% confidence interval 0.32–0.62, p < 0.001). KMA showed that trifecta patients had improved 5-yr freedom from CKD stage 3 (93.5% vs 57.7%, p < 0.001) and CKD upstaging (84.3% vs 8.2%, p < 0.001). Limitations include retrospective design. Conclusions: PN in elderly patients can be performed with acceptable quality outcomes. Trifecta was associated with decreased tumor complexity and improved functional preservation. Patient summary: We looked at quality outcomes after partial nephrectomy in elderly patients. Acceptable quality outcomes were achieved, measured by a composite outcome called trifecta, whose achievement was associated with improved kidney functional preservation. Partial nephrectomy in elderly patients provides quality outcomes as measured by trifecta. Tumor complexity is a key determinant for trifecta achievement, and trifecta attainment is associated with improved function. Increasing utilization of robotics has benefits in recovery without compromising quality.