Percutaneous ablation versus surgical resection for local recurrence following partial nephrectomy for renal cell cancer : a propensity score analysis (REPART study – UroCCR 71)

Membres du jury

M. le Professeur BENSALAH Karim | Président M. le Professeur BIGOT Pierre | Directeur M. le Docteur LEBDAI Souhil | Membre M. le Docteur KHENE Zine-Eddine | Membre

Soutenue publiquement le :

2019-2020

THÈSE

pour le

DIPLÔME D’ÉTAT DE DOCTEUR EN MÉDECINE

Qualification en CHIRURGIE GÉNÉRALE

Percutaneous ablation versus surgical resection for local recurrence following partial nephrectomy for renal cell cancer:

a propensity score analysis (REPART study – UroCCR 71)

Ablation percutanée versus résection chirurgicale pour une récidive locale après néphrectomie partielle pour un cancer à cellules rénales :

une analyse du score de propension (étude REPART – UroCCR 71)

BRASSIER Marie

Née le 11 juin 1988 à Rennes (35)

Sous la direction de M. le Professeur BIGOT Pierre

ENGAGEMENT DE NON PLAGIAT

Je, soussignée BRASSIER Marie ...

déclare être pleinement consciente que le plagiat de documents ou d’une partie d’un document publiée sur toutes formes de support, y compris l’internet, constitue une violation des droits d’auteur ainsi qu’une fraude caractérisée.

En conséquence, je m’engage à citer toutes les sources que j’ai utilisées pour écrire ce rapport ou mémoire.

Signé par l'étudiante le 01/09/2020

LISTE DES ENSEIGNANTS DE LA FACULTÉ DE SANTÉ D’ANGERS

Doyen de la Faculté : Pr Nicolas Lerolle

Vice-Doyen de la Faculté et directeur du département de pharmacie : Pr Frédéric Lagarce

Directeur du département de médecine : Pr Cédric Annweiler PROFESSEURS DES UNIVERSITÉS

ABRAHAM Pierre Physiologie Médecine

ANNWEILER Cédric Gériatrie et biologie du

vieillissement Médecine

ASFAR Pierre Réanimation Médecine

AUBE Christophe Radiologie et imagerie médicale Médecine

AUGUSTO Jean-François Néphrologie Médecine

AZZOUZI Abdel Rahmène Urologie Médecine

BAUFRETON Christophe Chirurgie thoracique et

cardiovasculaire Médecine

BENOIT Jean-Pierre Pharmacotechnie Pharmacie

BEYDON Laurent Anesthésiologie-réanimation Médecine

BIGOT Pierre Urologie Médecine

BONNEAU Dominique Génétique Médecine

BOUCHARA Jean-Philippe Parasitologie et mycologie Médecine

BOUVARD Béatrice Rhumatologie Médecine

BOURSIER Jérôme Gastroentérologie ; hépatologie Médecine

BRIET Marie Pharmacologie Médecine

CAILLIEZ Eric Médecine générale Médecine

CALES Paul Gastroentérologe ; hépatologie Médecine CAMPONE Mario Cancérologie ; radiothérapie Médecine CAROLI-BOSC François-xavier Gastroentérologie ; hépatologie Médecine CHAPPARD Daniel Cytologie, embryologie et

cytogénétique Médecine

CONNAN Laurent Médecine générale Médecine

COUTANT Régis Pédiatrie Médecine

CUSTAUD Marc-Antoine Physiologie Médecine

DE CASABIANCA Catherine Médecine Générale Médecine DESCAMPS Philippe Gynécologie-obstétrique Médecine D’ESCATHA Alexis Médecine et santé au Travail Médecine DINOMAIS Mickaël Médecine physique et de

réadaptation Médecine

DIQUET Bertrand Pharmacologie Médecine

DUBEE Vincent Maladies Infectieuses et

Tropicales Médecine

DUCANCELLE Alexandra Bactériologie-virologie ; hygiène

hospitalière Médecine

DUVAL Olivier Chimie thérapeutique Pharmacie

DUVERGER Philippe Pédopsychiatrie Médecine

EVEILLARD Mathieu Bactériologie-virologie Pharmacie FAURE Sébastien Pharmacologie physiologie Pharmacie

FOURNIER Henri-Dominique Anatomie Médecine

FURBER Alain Cardiologie Médecine

GAGNADOUX Frédéric Pneumologie Médecine

GARNIER François Médecine générale Médecine

GASCOIN Géraldine Pédiatrie Médecine

GOHIER Bénédicte Psychiatrie d'adultes Médecine GUARDIOLA Philippe Hématologie ; transfusion Médecine

GUILET David Chimie analytique Pharmacie

HAMY Antoine Chirurgie générale Médecine

HENNI Samir Chirurgie Vasculaire, médecine

vasculaire Médecine

HUNAULT-BERGER Mathilde Hématologie ; transfusion Médecine IFRAH Norbert Hématologie ; transfusion Médecine

JEANNIN Pascale Immunologie Médecine

KEMPF Marie Bactériologie-virologie ; hygiène

hospitalière Médecine

LACCOURREYE Laurent Oto-rhino-laryngologie Médecine

LAGARCE Frédéric Biopharmacie Pharmacie

LARCHER Gérald Biochimie et biologie moléculaires Pharmacie LASOCKI Sigismond

LEGENDRE Guillaume Anesthésiologie-réanimation

Gynécologie-obstétrique Médecine Médecine

LEGRAND Erick Rhumatologie Médecine

LERMITE Emilie Chirurgie générale Médecine

LEROLLE Nicolas Médecine Intensive-Réanimation Médecine LUNEL-FABIANI Françoise Bactériologie-virologie ; hygiène

hospitalière Médecine

MARCHAIS Véronique Bactériologie-virologie Pharmacie

MARTIN Ludovic Dermato-vénéréologie Médecine

MAY-PANLOUP Pascale Biologie et médecine du développement et De la reproduction

Médecine

MENEI Philippe Neurochirurgie Médecine

MERCAT Alain Réanimation Médecine

MERCIER Philippe Anatomie Médecine

PAPON Nicolas Parasitologie et mycologie

médicale Pharmacie

PASSIRANI Catherine Chimie générale Pharmacie

PELLIER Isabelle Pédiatrie Médecine

PETIT Audrey Médecine et Santé au Travail Médecine PICQUET Jean Chirurgie vasculaire ; médecine

vasculaire Médecine

PODEVIN Guillaume Chirurgie infantile Médecine

PROCACCIO Vincent Génétique Médecine

PRUNIER Delphine Biochimie et Biologie Moléculaire Médecine

PRUNIER Fabrice Cardiologie Médecine REYNIER Pascal Biochimie et biologie moléculaire Médecine RICHARD Isabelle Médecine physique et de

réadaptation Médecine

RICHOMME Pascal Pharmacognosie Pharmacie

RODIEN Patrice Endocrinologie, diabète et

maladies métaboliques Médecine ROQUELAURE Yves Médecine et santé au travail Médecine ROUGE-MAILLART Clotilde Médecine légale et droit de la

santé Médecine

ROUSSEAU Audrey Anatomie et cytologie

pathologiques Médecine

ROUSSEAU Pascal Chirurgie plastique,

reconstructrice et esthétique Médecine ROUSSELET Marie-Christine Anatomie et cytologie

pathologiques Médecine

ROY Pierre-Marie Thérapeutique Médecine

SAULNIER Patrick Biophysique et biostatistique Pharmacie

SERAPHIN Denis Chimie organique Pharmacie

TRZEPIZUR Wojciech Pneumologie Médecine

UGO Valérie Hématologie ; transfusion Médecine

URBAN Thierry Pneumologie Médecine

VAN BOGAERT Patrick Pédiatrie Médecine

VENIER-JULIENNE Marie-Claire Pharmacotechnie Pharmacie

VERNY Christophe Neurologie Médecine

WILLOTEAUX Serge Radiologie et imagerie médicale Médecine

MAÎTRES DE CONFÉRENCES

ANGOULVANT Cécile Médecine Générale Médecine

BAGLIN Isabelle Chimie thérapeutique Pharmacie

BASTIAT Guillaume Biophysique et biostatistique Pharmacie

BEAUVILLAIN Céline Immunologie Médecine

BELIZNA Cristina Médecine interne Médecine

BELLANGER William Médecine générale Médecine

BELONCLE François Réanimation Médecine

BENOIT Jacqueline Pharmacologie Pharmacie

BIERE Loïc Cardiologie Médecine

BLANCHET Odile Hématologie ; transfusion Médecine

BOISARD Séverine Chimie analytique Pharmacie

CAPITAIN Olivier Cancérologie ; radiothérapie Médecine

CASSEREAU Julien Neurologie Médecine

CHAO DE LA BARCA Juan-Manuel Médecine

CHEVALIER Sylvie Biologie cellulaire Médecine CLERE Nicolas Pharmacologie / physiologie Pharmacie

COLIN Estelle Génétique Médecine

DERBRE Séverine Pharmacognosie Pharmacie

DESHAYES Caroline Bactériologie virologie Pharmacie

FERRE Marc Biologie moléculaire Médecine

FORTRAT Jacques-Olivier Physiologie Médecine

HAMEL Jean-François Biostatistiques, informatique médicale Médicale HELESBEUX Jean-Jacques Chimie organique Pharmacie

HINDRE François Biophysique Médecine

KHIATI Salim Biochimie et biologie moléculaire Médecine JOUSSET-THULLIER Nathalie Médecine légale et droit de la santé Médecine JUDALET-ILLAND Ghislaine Médecine Générale Médecine KUN-DARBOIS Daniel Chirurgie Maxillo-Faciale et

Stomatologie Médecine

LACOEUILLE Franck Biophysique et médecine nucléaire Médecine

LEBDAI Souhil Urologie Médecine

LANDREAU Anne Botanique/ Mycologie Pharmacie

LEBDAI Souhil Urologie Médecine

LEGEAY Samuel Pharmacocinétique Pharmacie

LE RAY-RICHOMME Anne-

Marie Pharmacognosie Pharmacie

LEPELTIER Elise Chimie générale Pharmacie

LETOURNEL Franck Biologie cellulaire Médecine

LIBOUBAN Hélène Histologie Médecine

LUQUE PAZ Damien Hématologie; Transfusion Médecine MABILLEAU Guillaume Histologie, embryologie et

cytogénétique Médecine

MALLET Sabine Chimie Analytique Pharmacie

MAROT Agnès Parasitologie et mycologie médicale Pharmacie

MESLIER Nicole Physiologie Médecine

MOUILLIE Jean-Marc Philosophie Médecine

NAIL BILLAUD Sandrine Immunologie Pharmacie

PAILHORIES Hélène Bactériologie-virologie Médecine

PAPON Xavier Anatomie Médecine

PASCO-PAPON Anne Radiologie et imagerie médicale Médecine

PECH Brigitte Pharmacotechnie Pharmacie

PENCHAUD Anne-Laurence Sociologie Médecine

PIHET Marc Parasitologie et mycologie Médecine

PY Thibaut Médecine Générale Médecine

RAMOND-ROQUIN Aline Médecine Générale Médecine

RINEAU Emmanuel Anesthésiologie réanimation Médecine

RIOU Jérémie Biostatistiques Pharmacie

ROGER Emilie Pharmacotechnie Pharmacie

SAVARY Camille Pharmacologie-Toxicologie Pharmacie

SCHMITT Françoise Chirurgie infantile Médecine

SCHINKOWITZ Andréas Pharmacognosie Pharmacie

SPIESSER-ROBELET

Laurence Pharmacie Clinique et Education

Thérapeutique Pharmacie

TANGUY-SCHMIDT Aline TESSIER-CAZENEUVE Christine

Hématologie ; transfusion

Médecine Générale Médecine

Médecine

VENARA Aurélien Chirurgie générale Médecine

VIAULT Guillaume Chimie organique Pharmacie

PROFESSEURS EMERITES

Philippe MERCIER Neurochirurgie Médecine

Dominique CHABASSE Parasitologie et Médecine Tropicale Médecine

Jean-François SUBRA Néphrologie Médecine

AUTRES ENSEIGNANTS

AUTRET Erwan Anglais Médecine

BARBEROUSSE Michel Informatique Médecine

BRUNOIS-DEBU Isabelle Anglais Pharmacie

CHIKH Yamina Économie-Gestion Médecine

FISBACH Martine Anglais Médecine

O’SULLIVAN Kayleigh Anglais Médecine

REMERC IEMEN T S

Monsieur le Professeur Karim BENSALAH,

Professeur des Universités à la faculté de Rennes – Praticien Hospitalier, Chef de service d’urologie, CHU de Rennes

Vous me faîtes l’honneur de présider cette thèse.

Vous êtes une personne que j’admire depuis de nombreuses années et pour laquelle j’ai un immense respect. Je vous remercie de m’avoir donné envie de suivre votre voie. Mon seul regret est de ne pas avoir eu l’occasion de pouvoir m’instruire suffisamment auprès de vous. Vous êtes un grand Homme, une source d’inspiration.

Soyez assuré de mes sincères remerciements.

À mon Directeur de thèse,

Monsieur le Professeur Pierre BIGOT,

Professeur des Universités à la faculté d’Angers - Praticien Hospitalier, Chef de service d’urologie, CHU d’Angers

Merci pour votre soutien, votre bienveillance et votre disponibilité. Merci pour votre patience et votre apprentissage lors de ces trois mois passés à vos côtés. Vous resterez la personne m’ayant le plus formée pendant mon internat et je vous en remercie. J’espère que vous prendrez toujours le soin d’affiner ma formation.

Veuillez trouver ici l’expression de ma sincère reconnaissance et de mon profond respect.

À mes membres du jury,

Monsieur le Docteur Souhil LEBDAI,

Maître de Conférence des Universités à la faculté d’Angers, Département d’urologie, CHU d’Angers

Vous me faîtes l’honneur de juger mon travail.

Je vous remercie pour votre disponibilité et votre gentillesse lors de nos différents échanges.

Soyez assuré de ma reconnaissance.

Monsieur le Docteur Zine-Eddine KHENE,

Chef de Clinique des Universités à la faculté de Rennes- Assistant des Hôpitaux, Département d’urologie, CHU de Rennes

Je ne te remercierai jamais assez d’avoir éveillé ma curiosité scientifique et d’avoir pris du temps pour m’instruire tant sur le plan intellectuel que chirurgical. C’était un honneur pour moi de pouvoir travailler avec toi. Merci pour ta bienveillance et d’avoir toujours été là.

Tu peux être assuré de ma reconnaissance et de mon affection.

LIST OF ABBREVIATIONS

ASA American Society of Anesthesiologists BMI Body Mass Index

CKD-EPI Chronic Kidney Disease Epidemiology Collaboration DFS Disease Recurrence-Free Survival

ECOG PS Eastern Cooperative Oncology Group Performance Status eGFR Estimated Glomerular Filtration Rate

LR Local Recurrence

MFS Metastasis-Free Survival PCA Percutaneous Ablation PN Partial Nephrectomy

RCC Renal Cell Carcinoma/Cancer RN Radical Nephrectomy

Plan

LIST OF ABBREVIATIONS ABSTRACT

INTRODUCTION

PATIENTS AND METHODS RESULTS

DISCUSSION CONCLUSION REFERENCES LIST OF FIGURES LIST OF TABLES TABLE OF CONTENT

Percutaneous ablation versus surgical resection for local recurrence following partial nephrectomy for renal cell cancer: a propensity score

analysis

(REPART Study – UroCCR 71)

Marie BRASSIER ¹, Zine-Eddine KHENE ², Jean-Christophe BERNHARD ³, Van Thi DANG ⁴, Idir OUZAID ⁵, François Xavier NOUHAUD ⁶, Jonathan OLIVIER ⁷, Cosmina NEDELCU ⁸, Nicolas GRENIER ⁹, Luc BEUZIT ¹⁰, Nicolas DOUMERC ⁴, Karim BENSALAH ², Pierre BIGOT ¹

1: Department of Urology, Angers University Hospital, Angers, France 2: Department of Urology, Rennes University Hospital, Rennes, France 3: Department of Urology, Bordeaux University Hospital, Bordeaux, France

4: Department of Urology and Renal Transplantation, Toulouse University Hospital, Toulouse, France 5: Department of Urology, Bichat Hospital, APHP, Paris Diderot University, Paris, France

6: Department of Urology, Rouen University Hospital, Rouen, France 7: Department of Urology, Lille University Hospital, Lille, France

8: Department of Radiology, Angers University Hospital, Angers, France 9: Department of Radiology, Bordeaux University Hospital, Bordeaux, France 10: Department of Radiology, Rennes University Hospital, Rennes, France

Corresponding author:

Marie BRASSIER,

Department of Urology, Angers University Hospital, E-mail : [email protected]

ABSTRACT

Background: Data comparing percutaneous ablation (PCA) and surgical resection (SR) for an isolated local recurrence (LR) following partial nephrectomy (PN) for renal cell carcinoma (RCC) are lacking.

Objective: To examine outcomes between PCA versus SR for an isolated LR following PN for RCC.

Design, setting, and participants: Patients who underwent PN for RCC and developed LR between 2013 and 2019 were included. LR was defined as the appearance of a mass in contact with the resection bed or the development of a tumor in the same region of the homolateral kidney as the original site.

Intervention: PCA or SR.

Outcome measurements and statistical analysis: To achieve balance in baseline characteristics, we used inverse probability of treatment weighting (IPTW) based on propensity to receive treatment. Oncologic outcomes, complications and renal function were evaluated between groups using logistic, linear and Cox proportional hazards regression models.

Results and limitations: 81 patients with isolated LR were included (PCA: 42; SR:39).

Median follow-up was 23 months. After adjustment, excellent balance was achieved for the majority of propensity score variables. In IPTW analysis, PCA was associated with a lower risk of post-operative complications (OR = 0.22; p = 0.006) and a smaller change in eGFR (beta

= -16.18; p = 0.001). There were no significant differences in the risk of disease recurrence

(HR = 0.72; p = 0.61), new LR (HR = 1.51; p = 0.59) and distant metastasis (HR = 0.19; p

= 0.09). Limitations include the sample size and unmeasured confounding factors.

Conclusion: Our results suggest that PCA provides comparable oncological outcomes to repeat surgery with fewer complications and better renal function preservation for the management of a LR after PN.

Patient summary: This report shows that PCA can be used for treating a LR after PN without significantly compromising cancer control.

INTRODUCTION

Renal cell carcinoma (RCC) is among the 10 most common malignancies and accounts for 3%–

5% of adult malignant neoplasms [1]. Partial nephrectomy (PN) is the preferred treatment for clinically localized RCC that offers similar oncologic outcomes and superior renal, cardiovascular and survival outcomes compared to radical nephrectomy [2].

The recent years have been marked by a growth in the use of PN for more challenging, larger and complex renal masses and thus potentially more aggressive cancer [3]. This has led to an overall increase in the number of tumors found to have adverse pathological feature (higher tumor grade, advanced tumor stage unfavorable histological subtypes, positive surgical margins) [4,5] and consequently a higher incidence of oncological failures would be expected.

Treatment of locale recurence (LR) after PN may constitute a clinically challenging situation.

Only a few studies specifically focused their attention on oncological and functionals outcomes and the data on this issue are limited [6]. Consequently, questions remain regarding the optimal therapeutic approach for these lesions: 1) Completion nephrectomy is an excellent option to achieve oncological control but puts patients at risk of Chronic Kidney Disease (CKD) [7]. 2) Repeat nephron sparing surgery is technically challenging and associated with significant morbidity [8]. 3) Percutaneous ablation (PCA) such as radiofrequency ablation or cryotherapy are increasingly utilized and seems to be an interesting alternative option with promising initial results [9].

The purpose of this study was to compare the postoperative complications, renal function and oncologic outcomes between patients undergoing PCA and renal surgery for an isolated LR following PN for RCC.

PATIENTS AND METHODS

Study design and patient population

After institutional review board approval, the REPART study was conducted in the framework of the UroCCR project (NCT03293563). We reviewed the data of patients who were prospectively included in the UroCCR database after written consent (CNIL authorization number DR-2013-206) between 2013 and 2019 and experienced locally recurrent disease after initial PN for sporadic clinically localized RCC at seven academic medical centers. Patients with less than 6 months of follow-up (n=2), non RCC pathology (n=1), patients with history of contralateral RCC (n=6) or detectable distant metastatic disease at the time of LR (n =12) were excluded.

LR was defined as an enhancing mass within the operated renal fossa or the development of a new enhancing mass within the surgical bed of the original partial nephrectomy site or within the same region of the ipsilateral kidney as the original partial nephrectomy site [10,11].

Definitive diagnosis of recurrence was assigned after tissue confirmation. Metachronous lesions in the ipsilateral kidney away from the original PN bed, ipsilateral adrenal gland, ipsilateral retroperitoneal lymph nodes were not considered LR.

Covariates

Demographics, tumor and pathological characteristics at the time of PN and disease recurrence were collected in the UroCCR database. Demographics included age, gender, Eastern Cooperative Oncology Group Performance Status [ECOG PS], American Society of Anesthesiologists [ASA] classification, body mass index [BMI]. Tumors’ characteristics included tumor size, tumor side, RENAL nephrometry score. Pathologic data included stage, Fuhrman

grade, surgical margins, histologic subtype, microscopic vascular invasion and sarcomatoid features.

Follow-up protocol and treatment of recurrence

Postoperative follow-up was institution- and physician- dependent, but generally followed national and international guidelines. That usually, comprised an outpatient visit at 1 month postoperatively, then every 6 months for two years and annually for at least three additional years. Follow-up consisted of a disease-specific history assessment, physical examination and contrast-enhanced computed tomography of the chest, abdomen and pelvis. Patients’ LR treatment decision was at the discretion of the surgeon and the oncologist. If they opted for PCA a referral was then made to an interventional radiologist.

Outcomes

Postoperative complications were classified according to the Clavien–Dindo system for each procedure [12]. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula.

The oncological outcomes were disease recurrence-free survival (DFS), defined as the time from LR’s treatment to a diagnosis of new local or distant recurrence. Metastasis-free survival (MFS) was defined as the time from LR’s treatment to a diagnosis of distant recurrence.

Patients free of second recurrence on last follow up were censored.

Statistical Analysis

Continuous variables were reported as medians and interquartile ranges (IQRs) and categorical variables were reported as proportions. We used the standardized differences approach (as

opposed to two-sample t test and x2 test) to compare covariates between patients who undergo PCA versus surgical resection to facilitate assessment for possible confounding. This quantitative method allowed us to assess the balance in baseline characteristics between treatment groups [13]. A standardized difference ≥ 10% for a given covariate indicated a significant imbalance.

To account for selection bias, observed differences in baseline characteristics between patients who undergo PCA versus surgery were controlled for with a weighted propensity score analysis.

The propensity (or probability) of being in the two treatment groups was estimated using a logistic regression model based on age, sex, ECOG PS, recurrence size, baseline eGFR, tumor histology, time of recurrence. Each patient was weighted by the inverse probability of being in the PCA versus surgery group, with the goal of balancing observable characteristics between the two groups; this approach is known as inverse probability of treatment weighting (IPTW) [14]. Balance between covariates in weighted groups was also assessed by using the standardized differences approach and by comparing their distribution with unweighted data.

The risk of a postoperative complication was compared between groups using logistic regression, while percent drop in eGFR at discharge was evaluated using linear regression. The risk of disease recurrence and distant metastasis was compared between groups using Cox proportional hazards regression. Finally, a sensitivity analysis was performed in order to evaluate the outcomes in the subgroup of patients undergoing PCA or PN.

Statistical analyses were performed using Stata 14.1 statistical software (Stata, College Station, TX, USA). All tests were two-sided with a significance level at p<0.05.

RESULTS

Patients and tumor characteristics at time of partial nephrectomy

Clinical and pathological baseline characteristics of patients are summarized in Table 1. A total of 81 patients were included for analysis. There were 62 (77%) males and 19 (23%) females.

Median age was 65 years (IQR: 57–72), BMI was 27 kg/m2 (IQR: 23–31). Tumor size was 4 cm (IQR: 2.7–5). Surgery for primary tumor was performed by open, laparoscopic and robotic approach in 25 (31%), 15 (18%) and 41 (51%) cases, respectively. Pathological stages were 70% pT1, 6% pT2, and 24% pT3. There were 41 (51%) Fuhrman III-IV and 6 (7%) sarcomatoid feature. There were 11 (14%) cases of positive margins on final pathology.

Median time from PN to LR was 21 months (IQR: 11–31).

Patient characteristics at time of local recurrence in the unweighted and weighted cohort

Patients’ characteristics at time of LR are summarized in Table 2. Median follow- up after LR was 23 months (IQR 9-42). 42 patients underwent PCA and 39 had surgical resection. Before adjustment, patients who underwent PCA were older (median 69 vs 66 yr), had worse performance status (ECOG PS score ≥ 1: 50 % vs 42 %), worse baseline renal function (median 80 vs 83.5 ml/min/1.73 m2), lower clear RCC (81% vs 87%) and smaller tumors (median 2 vs 3 cm) (all standardized differences ≥ 10 %). The surgical approach among patients who underwent surgical resection was radical nephrectomy (RN) in 31 (79 %) patients and PN in eight (21 %) patients.

Upon IPTW adjustment, excellent balance was achieved for the majority of propensity score variables (standardized differences < 10 %), while minor imbalances remained for gender (standardized difference = 0.13).

Perioperative complications

Overall, 18 patients (22%) had a complication including 2 (5%) in the PCA group and 16 (41%) in the surgical resection group. In unadjusted analysis (Table 2), the probability of having any post-treatment complication was lower after PCA versus surgical resection (odds ratio [OR] = 0.07; 95% CI [0.01, 0.34]; p = 0.001). Upon IPTW adjustment significant difference was observed in the probability of any post-treatment complication between PCA and surgical resection (OR = 0.22; 95% CI [0.06, 0.38]; p = 0.006) (Table 3).

Renal function outcomes

In the unweighted analysis (Table 3), there was a smaller change in eGFR following PCA versus surgical resection (beta = -12.72; 95% CI [-23, -1.71]; p = 0.004). In the IPTW analysis, the difference remained significant in change in eGFR (beta = -16.18; 95% CI [-23, -9]; p =

<0.001) between PCA and surgery (Table 3).

Oncologic outcomes

32 patients (40%) experienced disease recurrence (local or distant) following treatment of LR.

Among them, 16 (20%) developed a new LR (8 in PCA group and 8 in surgical resection group)

and 22 (27%) developed distant metastases (4 in PCA group and 18 in surgical resection group).

In both unweighted and IPTW analysis, there were no significant differences in the risk of disease recurrence with PCA versus surgical resection (hazard ratio [HR] = 0.53; 95% CI [0.25, 1.11]; p = 0.1 and HR = 0.72; 95% CI [0.2, 2.57]; p = 0.61; respectively; Table 3).

There were no significant differences in the risk of new LR between PCA versus surgery in both unweighted and IPTW analysis (HR = 1.11; 95% CI [0.41, 2.95]; p = 0.85 and HR = 1.51;

95% CI [0.32, 6.98]; p = 0.59; Table 3). In unadjusted analysis, the risk of distant metastasis disease recurrence was lower after PCA versus surgical resection (HR = 0.22; 95% CI [0.07, 0.68]; p = 0.008). However, in the IPTW-adjusted analysis, there were no significant differences in the risk of distant metastasis with PCA versus surgical resection (HR = 0.19;

95% CI [0.04, 1.12]; p = 0.09; Table 3).

Sensitivity analyses

Given that our main analysis included both partial and radical nephrectomy in the surgery group, we performed a subgroup analysis restricting to compare PCA vs. PN. We found no significant differences in the risk of post-operative complication after PCA versus PN (odds ratio [OR] = 0.43; 95% CI [0.03, 5.52]; p = 0.52). There was no significant difference in change in eGFR (beta = – 8; p = 0.24) and no difference regarding the risk of disease recurrence following PCA versus PN (hazard ratio [HR] = 0.67; 95% CI [0.21, 2.14]; p = 0.51;

Table 4).

DISCUSSION

Isolated LR of RCC after PN represent a clinically challenging situation. In addition to the need for satisfactory cancer control, it is necessary to preserve sufficient renal function to avoid end-stage renal disease, which is associated with increased rates of cardiovascular events, hospitalization and death [15]. Options for treating patients with a LR after PN include active surveillance, therapy ablation or surgical salvage therapy [6]. In the last decade, PCA has emerged as an interesting therapeutic option for patients with LR, whether it can achieve comparable survival outcomes compared with surgical resection remains unclear.

In this study we compare the risk of having a complication, renal function outcomes and cancer outcomes between patients undergoing PCA or surgical excision for a LR of RCC after PN. Our hypothesis stated that PCA might be less morbid than surgery with equivalent oncological outcomes. The results of the study confirmed our hypothesis and several relevant observations deserve further discussion.

First, our complication rate was significantly higher after surgery compared to PCA. Both RN and repeated PN after initial failed PN have been described as alternatives. Most related studies focused on surgically complex and challenging PN and the majority report on just one treatment modality. None comparative studies have been reported. Johnson et al reported a major perioperative complication rate of 19.6% in 51 cases of repeat partial nephrectomy, including a mortality rate of 1.9% [16]. Liu et al reported a 52% perioperative complication rate and 4% mortality in 25 patients treated with repeat partial nephrectomy on a solitary kidney [17]. Magera et al also reported a major perioperative complication rate of 28% in treatment of 18 patients with repeat nephron sparing surgery [18]. These findings are in accordance with other smaller series, in which relatively high complication rates were observed

[19,20]. In contrast, PCA approach for LR seems to be less morbid. Complication rates were low (0–6%) and few treatment-related major complications were observed [21,22].

Second, we examined the effect of both PCA and surgery on renal function. As expected, we found a better preservation of renal function for PCA. When performing a sensitivity analysis comparing PCA vs only PN, that result found not significant. There are no studies comparing renal function outcomes after LR management for localized RCC. Zhou et al reported the case of 8 patients who relapsed after PN and were treated by radiofrequency, renal function was overall stable without significant change at 1 month and last follow-up compared to renal function before ablation (eGFR: p = 0.21; creatinine: p = 0.10) [23]. However, the power of the analysis is low. In a small series of 26 patients undergone repeat robotic partial nephrectomy, Watson et al. found no significant difference between median preoperative and latest postoperative median estimated glomerular filtration rates [19].

Third, our study analyzed the oncologic outcomes of the management of a LR (initially treated with PN) by PCA vs surgery with and without adjustment of the groups. It suggests that there is no significant difference between the two groups in the appearance of a new LR (adjusted and unadjusted groups) and the appearance of metastasis (only adjusted group). Only one previous study investigated oncological outcomes after PCA in the management of LR for localized RCC but did not compare different treatment options. Zhou et al showed that ablative therapy could be an interesting approach in the treatment of LR after PN. Local progression- free and overall survival rate were 91%, 91% and 82% during mean follow-up time of 2.5 years (range 0.1-7.1). Unfortunately, they included only 8 patients with a very short follow- up time [23] .

Notable strengths of this study include our use of IPTW- adjusted analyses to account for differences in factors that may have influenced patient selection as well as patient outcomes.

Moreover, this is the first comparative effectiveness study in the LR after PN to focus specifically on comparison between PCA and surgical excision of the relapse.

This study has several limitations. The major shortcomings were those inherent to the retrospective design although all patients were prospectively enrolled in the UroCCR project.

Second, although this is a large study relative to existing literature, the sample size is still relatively small especially for salvage PN. Third, there is currently no standardized definition of LR after surgery of RCC and there is considerable heterogeneity in defining LR in the current literature [24]. Fourth, given that adverse oncologic outcomes were relatively rare in this cohort, additional follow-up may provide improved power to identify statistically significant differences among the treatments longer follow-ups will be needed to better assess oncologic outcomes. Finally, caution should be applied before generalizing our findings and outcomes to settings with less experience with surgical resection and/ or PCA. Despite these limitations, this study provides the first large cohort comparison of outcomes between the two approaches.

We believe that additional studies and clinical trials are warranted, as there remains a need for high-quality prospective data.

CONCLUSION

PCA provides comparable oncological outcomes to salvage surgery, fewer complications and better renal function preservation. Although the findings are subject to the usual biases related to the observational study design, these preliminary data suggest that PCA seems to be an attractive alternative for LR management after PN.

REFERENCES

[1] Capitanio U, Bensalah K, Bex A, Boorjian SA, Bray F, Coleman J, et al. Epidemiology of Renal Cell Carcinoma. European Urology 2019;75:74–84. https://doi.org/10.1016/j.eururo.2018.08.036.

[2] Ljungberg B, Albiges L, Abu-Ghanem Y, Bensalah K, Dabestani S, Fernández-Pello S, et al.

European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update. European Urology 2019;75:799–810. https://doi.org/10.1016/j.eururo.2019.02.011.

[3] Mir MC, Derweesh I, Porpiglia F, Zargar H, Mottrie A, Autorino R. Partial Nephrectomy Versus Radical Nephrectomy for Clinical T1b and T2 Renal Tumors: A Systematic Review and Meta-analysis of

Comparative Studies. European Urology 2017;71:606–17.

https://doi.org/10.1016/j.eururo.2016.08.060.

[4] Maurice MJ, Zhu H, Kim SP, Abouassaly R. Increased use of partial nephrectomy to treat high- risk disease. BJU Int 2016;117:E75-86. https://doi.org/10.1111/bju.13262.

[5] Gorin MA, Ball MW, Pierorazio PM, Tanagho YS, Bhayani SB, Kaouk JH, et al. Outcomes and predictors of clinical T1 to pathological T3a tumor up-staging after robotic partial nephrectomy: a multi- institutional analysis. J Urol 2013;190:1907–11. https://doi.org/10.1016/j.juro.2013.06.014.

[6] Kriegmair MC, Bertolo R, Karakiewicz PI, Leibovich BC, Ljungberg B, Mir MC, et al. Systematic Review of the Management of Local Kidney Cancer Relapse. Eur Urol Oncol 2018;1:512–23.

https://doi.org/10.1016/j.euo.2018.06.007.

[7] Shah P, Patel VR, Kozel Z, Vira M, Myers A, Kaplan-Marans E, et al. Laparoscopic Completion Nephrectomy for Local Surgical Bed Recurrence After Partial Nephrectomy: An Analysis of Procedural Complexity and Feasibility. Journal of Endourology 2018;32:1114–9.

https://doi.org/10.1089/end.2018.0384.

[8] Autorino R, Khalifeh A, Laydner H, Samarasekera D, Rizkala E, Eyraud R, et al. Repeat robot- assisted partial nephrectomy (RAPN): feasibility and early outcomes. BJU Int 2013;111:767–72.

https://doi.org/10.1111/j.1464-410X.2013.11800.x.

[9] Morgan MA, Roberts NR, Pino LA, Trabulsi EJ, Brown DB, Gomella LG, et al. Percutaneous cryoablation for recurrent low grade renal cell carcinoma after failed nephron-sparing surgery. Can J Urol 2013;20:6933–7.

[10] Wood EL, Adibi M, Qiao W, Brandt J, Zhang M, Tamboli P, et al. Local Tumor Bed Recurrence Following Partial Nephrectomy in Patients with Small Renal Masses. Journal of Urology 2018;199:393–

400. https://doi.org/10.1016/j.juro.2017.09.072.

[11] Mouracade P, Kara O, Maurice MJ, Dagenais J, Malkoc E, Nelson RJ, et al. Patterns and Predictors of Recurrence after Partial Nephrectomy for Kidney Tumors. Journal of Urology 2017;197:1403–9.

https://doi.org/10.1016/j.juro.2016.12.046.

[12] Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13.

[13] Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med 2009;28:3083–107.

https://doi.org/10.1002/sim.3697.

[14] Austin PC. The use of propensity score methods with survival or time-to-event outcomes:

reporting measures of effect similar to those used in randomized experiments. Stat Med 2014;33:1242–

58. https://doi.org/10.1002/sim.5984.

[15] Kates M, Badalato GM, Pitman M, McKiernan JM. Increased Risk of Overall and Cardiovascular Mortality After Radical Nephrectomy for Renal Cell Carcinoma 2 cm or Less. The Journal of Urology 2011;186:1247–53. https://doi.org/10.1016/j.juro.2011.05.054.

[16] Johnson A, Sudarshan S, Liu J, Linehan WM, Pinto PA, Bratslavsky G. Feasibility and Outcomes of Repeat Partial Nephrectomy. Journal of Urology 2008;180:89–93.

https://doi.org/10.1016/j.juro.2008.03.030.

[17] Liu NW, Khurana K, Sudarshan S, Pinto PA, Linehan WM, Bratslavsky G. Repeat Partial Nephrectomy on the Solitary Kidney: Surgical, Functional, and Oncologic Outcomes. J Urol 2010;183:1719–24. https://doi.org/10.1016/j.juro.2010.01.010.

[18] Magera JS, Frank I, Lohse CM, Leibovich BC, Cheville JC, Blute ML. Analysis of repeat nephron sparing surgery as a treatment option in patients with a solid mass in a renal remnant. J Urol 2008;179:853–6. https://doi.org/10.1016/j.juro.2007.10.049.

[19] Watson MJ, Sidana A, Diaz AW, Siddiqui MM, Hankins RA, Bratslavsky G, et al. Repeat Robotic Partial Nephrectomy: Characteristics, Complications, and Renal Functional Outcomes. J Endourol 2016;30:1219–26. https://doi.org/10.1089/end.2016.0517.

[20] Bratslavsky G, Liu JJ, Johnson AD, Sudarshan S, Choyke PL, Linehan WM, et al. Salvage partial nephrectomy for hereditary renal cancer: feasibility and outcomes. J Urol 2008;179:67–70.

https://doi.org/10.1016/j.juro.2007.08.150.

[21] Hegg RM, Schmit GD, Boorjian SA, McDonald RJ, Kurup AN, Weisbrod AJ, et al. Percutaneous renal cryoablation after partial nephrectomy: technical feasibility, complications and outcomes. J Urol 2013;189:1243–8. https://doi.org/10.1016/j.juro.2012.10.066.

[22] Yang B, Autorino R, Remer EM, Laydner HK, Hillyer S, Altunrende F, et al. Probe ablation as salvage therapy for renal tumors in von Hippel-Lindau patients: the Cleveland Clinic experience with 3 years follow-up. Urol Oncol 2013;31:686–92. https://doi.org/10.1016/j.urolonc.2011.05.008.

[23] Zhou W, Herwald SE, Uppot RN, Arellano RS. Image-Guided Thermal Ablation for Non- resectable Recurrence of Renal Cell Cancer Following Nephrectomy: Clinical Experience with Eleven Patients. Cardiovasc Intervent Radiol 2018;41:1743–50. https://doi.org/10.1007/s00270-018-1976- 2.

[24] Lee Z, Jegede OA, Haas NB, Pins MR, Messing EM, Manola J, et al. Local Recurrence Following Resection of Intermediate-High Risk Nonmetastatic Renal Cell Carcinoma: An Anatomical Classification and Analysis of the ASSURE (ECOG-ACRIN E2805) Adjuvant Trial. Journal of Urology 2020;203:684–

9. https://doi.org/10.1097/JU.0000000000000588.

LIST OF FIGURES

Figure 1 : Flow chart of patients ... 18

Figure 1. Flow chart of patients Patients experienced locally recurrent disease

after initial partial nephrectomy for sporadic clinically localized RCC

n=102

Patients included for analysis n=81

Surgical resection n=39

Percutaneous ablation n=42

Patients excludded:

- Less than 6 months of follow- up (n=2) - NonRCC pathology (n=1)

- History of contralateral RCC (n=6)

- Detectable distant metastatic disease at the time of LR (n=12)

LIST OF TABLES

Table I. Clinical and pathological characteristics of the 81 patients at the time of partial nephrectomy ... 20 Table II. Patient characteristics at time of local recurrence in the unweighted and weighted cohort ... 21 Table III. Models comparing outcomes between percutaneous ablation and surgical resection for local recurrence following partial nephrectomy for renal cell cancer ... 22 Table IV. Sensitivity analyses: Models comparing outcomes between percutaneous ablation (n=42) and partial nephrectomy (n=8) for local recurrence following partial nephrectomy for renal cell cancer. ... 23

Table I. Clinical and pathological characteristics of the 81 patients at the time of partial nephrectomy

Age, median (IQR) 65 (57-72)

Gender, n (%)

Male 62 (77)

Female 19 (23)

BMI, median (IQR) 27 (23-31)

ECOG, n (%)

0 62 (77)

≥ 1 19 (23)

ASA classification (%)

1-2 63 (78)

3-4 18 (22)

Surgical approach, n (%)

Open 25 (31)

Laparoscopic 15 (18)

Robotic 41 (51)

Tumor size, median (IQR) 4 (2.7-5)

R.E.N.A.L. score, median (IQR) 7 (6-9)

Tumor side, n (%)

Right 38 (47)

Left 43 (53)

Tumor histology, n (%)

Clear cell 68 (84)

Papillary 9 (11)

Chromophobe 3 (4)

Other 1 (1)

Positive surgical margin, n (%) 11 (14)

Tumor pathologic stage, n (%)

1 57 (70)

2 5 (6)

3 19 (24)

Sarcomatoid differentiation, n (%) 6 (7)

Lymphovascular invasion, n (%) 12 (15)

Necrosis, n (%) 26 (32)

Fuhrman grade, n (%)

1-2 36 (49)

3-4 41 (51)

Time between PN-LR (months), median (IQR) 21 (11-31)

Table II. Patient characteristics at time of local recurrence in the unweighted and weighted cohort

Unweighted cohort Weighted cohort

PCA (n=42)

Surgical resection (n=39)

Standardized Difference, %

PCA (n=42)

Surgical resection (n=39)

Standardized Difference, %

Age, median (IQR) 69 (61-76) 66 (58-75) 0.20 68 (64-75) 71 (66-76) 0.004

Gender, n (%)

Male 31 (74) 31 (79) - 0.13 64% 79% 0.13

Female 11 (26) 8 (21) 36% 21%

ECOG score, n (%)

0 19 (50) 21 (58) - 0.17 69% 68% - 0.03

≥ 1 19 (50) 15 (42) 31% 32%

Time between PN-LR (months), median (IQR) 20 (14-33) 24 (9-31) 0.38 30 (18-80) 31 (18-34) 0.03 Recurrence tumour size (cm), median (IQR) 2 (1.6-2.4) 3 (2.5-4) - 1.26 2.3 (1.8-2.5) 2.5 (2.4-3) - 0.06 Baseline eGFR (ml/min/1.73 m2), median (IQR) 80 (60-86) 83.5 (66-97) - 0.4 82 (60-103) 78 (67-84) 0.1 Tumor histology, n (%)

Clear RCC 34 (81) 34 (87) 0.16 90% 91% - 0.002

Other 8 (19) 5 (13) 10% 9%

eGFR = estimated glomerular filtration rate; IQR = interquartile range; PCA = percutaneous ablation; RCC = renal cell carcinoma;

The propensity to undergo surgical resection versus PCA was estimated using a logistic regression model based on age at recurrence, gender, ECOG PS, time since PN, recurrence size, baseline eGFR, RCC tumor histology. All patients were included in the weighted analysis.

Table III. Models comparing outcomes between percutaneous ablation and surgical resection for local recurrence following partial nephrectomy for renal cell cancer

Unweighted analysis IPTW analysis

Binary outcome Any complication

Yes 22% (n = 18)

No 78 % (n = 63)

OR 95% CI p value OR 95% CI p value

0.07 (0.01, 0.34) 0.001 0.22 (0.06, 0.38) 0.006

Continous outcome Absolute change in eGFR

Median -16 ml/min/1.73m2

Interquartile range (-37, 0)

Beta 95% CI p value Beta 95% CI p value

- 12.72 (-23, - 1.71) 0.004 -16.18 (- 23, - 9) <0.001

Time- to-event outcomes Disease recurrence

Yes 40% (n = 32)

No 60% (n = 49)

HR 95% CI p value HR 95% CI p value

0.53 (0.25, 1.11) 0.1 0.72 (0.2, 2.57) 0.61

New LR

Yes 20% (n = 16)

No 80% (n = 65)

HR 95% CI p value HR 95% CI p value

1.11 (0.41, 2.95) 0.85 1.51 (0.32, 6.98) 0.59

Distant metastasis

Yes 27% (n = 22)

No 73% (n = 59)

HR 95% CI p value HR 95% CI p value

0.22 (0.07, 0.68) 0.008 0.19 (0.04, 1.12) 0.09

IPTW = inverse probability of treatment weighting; CI = confidence interval; eGFR = estimated glomerular filtration rate; HR = hazard ratio; OR = odds ratio; RCC = renal cell carcinoma, LR = local recurrence

Table IV. Sensitivity analyses: Models comparing outcomes between percutaneous ablation (n=42)

and partial nephrectomy (n=8) for local recurrence following partial nephrectomy for renal cell cancer.

Binary outcomes OR 95% CI p value

Any complication 0.43 (0.03, 5.52) 0.52

Continuous outcomes Beta 95% CI p value

Absolute change in eGFR -8 (-15, 4) 0.24

Time-to-event outcomes HR 95% CI p value

Disease recurrence 0.67 (0.21, 2.14) 0.51

TABLE OF CONTENT

ABSTRACT ... 2

INTRODUCTION ... 4

PATIENTS AND METHODS ... 5

RESULTS ... 8

DISCUSSION ... 11

CONCLUSION ... 14

REFERENCES ... 15

LIST OF FIGURES ... 17

LIST OF TABLES ... 19

TABLE OF CONTENT ... 24

Serment d'Hippocrate

Je jure par Apollon médecin, par Asclépios, par Hygie et Panacée, par tous les dieux et toutes les déesses, les prenant à témoin,

de remplir, selon ma capacité et mon jugement, ce serment et ce contrat ; de considérer d'abord mon maître en cet art à l'égal de mes propres parents ; de mettre à sa disposition des subsides et, s'il est dans le besoin, de lui transmettre une

part de mes biens ;

de considérer sa descendance à l'égal de mes frères, et de leur enseigner cet art, s'ils désirent l'apprendre, sans salaire ni contrat ;

de transmettre, les préceptes, des leçons orales et le reste de l'enseignement à mes fils, à ceux de mon maître, et aux disciples liés par un contrat et un serment, suivant la loi

médicale, mais à nul autre.

J'utiliserai le régime pour l'utilité des malades, suivant mon pouvoir et mon jugement ; mais si c'est pour leur perte ou pour une injustice à leur égard, je jure d'y faire obstacle.

Je ne remettrai à personne une drogue mortelle si on me la demande, ni ne prendrai l'initiative d'une telle suggestion.

De même, je ne remettrai pas non plus à une femme un pessaire abortif.

C'est dans la pureté et la piété que je passerai ma vie et exercerai mon art.

Je n'inciserai pas non plus les malades atteints de lithiase, mais je laisserai cela aux hommes spécialistes de cette intervention.

Dans toutes les maisons où je dois entrer, je pénétrerai pour l'utilité des malades, me tenant à l'écart de toute injustice volontaire, de tout acte corrupteur en général, et en particulier des relations amoureuses avec les femmes ou les hommes, libres ou esclaves.

Tout ce que je verrai ou entendrai au cours du traitement, ou même en dehors du traitement, concernant la vie des gens, si cela ne doit jamais être répété au-dehors, je le

tairai, considérant que de telles choses sont secrètes.

Eh bien donc, si j'exécute ce serment et ne l'enfreins pas, qu'il me soit donné de jouir de ma vie et de mon art, honoré de tous les hommes pour l'éternité. En revanche, si je le viole et

que je me parjure, que ce soit le contraire.

Traduction : J. Jouanna, Hippocrate, Paris, Librairie Arthème Fayard, 1992, annexe I.

(Portrait d'Hippocrate de Cos, Paris - Bibliothèque nationale, manuscrit grec 2144, f° 10 v°, XIVe siècle)

BRASSIER Marie

Percutaneous ablation versus surgical resection for local recurrence following partial nephrectomy for renal cell cancer: a propensity score analysis

(REPART study – UroCCR 71)

Keywords: local recurrence, partial nephrectomy, percutaneous ablation, renal cell carcinoma, outcome, surgery

Ablation percutanée versus résection chirurgicale pour une récidive locale après néphrectomie partielle pour un cancer à cellules rénales : une analyse du score de

propension (étude REPART – UroCCR 71)

Mots-clés : récidive locale, néphrectomie partielle, ablation percutanée, carcinome à cellules rénales, résultat, chirurgie

AB ST RAC T

Objective: To examine outcomes between PCA versus SR for an isolated LR following PN for RCC.

Patients and methods: Patients who underwent PN for RCC and developed LR between 2013 and 2019 were included.

LR was defined as the appearance of a mass in contact with the resection bed or in the operated renal fossa or the development of a tumor in the same region of the homolateral kidney as the original site. We stratified our cohort into two groups according to the treatment of LR: PCA vs SR. To achieve balance in baseline characteristics, we used inverse probability of treatment weighting (IPTW) based on propensity to receive treatment. Oncologic outcomes, complications and renal function were evaluated between groups using logistic, linear and Cox proportional hazards regression models.

Results: 81 patients with isolated LR were included (PCA: 42; SR:39). Median follow-up was 23 months. After adjustment, excellent balance was achieved for the majority of propensity score variables. In IPTW analysis, PCA was associated with a lower risk of post-operative complications (OR = 0.22; p = 0.006) and a smaller change in eGFR (beta

= -16.18; p = 0.001). There were no significant differences in the risk of disease recurrence (HR = 0.72; p = 0.61), new LR (HR = 1.51; p = 0.59) and distant metastasis (HR = 0.19, p = 0.09).

Conclusion: Our results suggest that PCA provides comparable oncological outcomes to repeat surgery with fewer complications and better renal function preservation for the management of a LR after PN.

R É S UM É

Objectif : Examiner les résultats entre l’APC et la chirurgie pour une RL isolée après NP pour un CCR.

Patients et méthodes : Les patients ayant eu une NP pour un CCR et qui ont développé une RL entre 2013 et 2019 ont été inclus. La RL a été définie par l’apparition d’une masse au contact du lit de résection ou dans la fosse rénale opérée ou le développement d’une tumeur dans la même région du rein homolatéral que le site d’origine. Nous avons stratifié notre cohorte en deux groupes selon le traitement de la RL : APC vs chirurgie. Pour équilibrer les caractéristiques de base, nous avons utilisé la probabilité inverse de pondération du traitement (score de propension). Les résultats oncologiques, les complications et la fonction rénale ont été évalués en utilisant une régression logistique, une régression linéaire et un modèle de Cox.

Résultats : 81 patients ont été inclus (APC : 42 ; chirurgie : 39). Le suivi médian était de 23 mois. Après pondération, un excellent équilibre a été obtenu dans la majorité des variables du score de propension. Dans l’analyse pondérée, l’APC était associée à un taux moindre de complications (OR = 0,22 ; p = 0,006) et une moindre dégradation de la fonction rénale (beta = -16,18 ; p = 0,001). Il n’y avait pas de différence significative dans le risque de récidive de la maladie (HR

= 0,72 ; p = 0,61), d’une nouvelle RL (HR = 1,51 ; p = 0,59) et de métastase à distance (HR = 0,19 ; p = 0,09).

Conclusion : Nos résultats suggèrent que l’APC offre des résultats oncologiques similaires à ceux d’une chirurgie répétée avec moins de complications et une meilleure préservation de la fonction rénale dans le traitement d’une RL après NP.