SciELO - Scientific Electronic Library Online

vol.72 número5The Role of Beta-1 Receptor Gene Polymorphism in Beta-Blocker Therapy for Vasovagal SyncopeMetabolic Syndrome Instead of Aflatoxin-Related TP53 R249S Mutation as a Hepatocellular Carcinoma Risk Factor índice de autoresíndice de materiabúsqueda de artículos
Home Pagelista alfabética de revistas  

Servicios Personalizados




Links relacionados

  • No hay artículos similaresSimilares en SciELO


Revista de investigación clínica

versión On-line ISSN 2564-8896versión impresa ISSN 0034-8376

Rev. invest. clín. vol.72 no.5 Ciudad de México sep./oct. 2020  Epub 09-Abr-2021 

Original articles

Characteristics and Surgical Outcomes in Very Elderly Patients (≥75 years) with Renal Cell Carcinoma: Data from the Latin American Renal Cancer Group

Adrián M. Garza-Gangemi1 

Ricardo A. Castillejos-Molina1 

Guillermo Gueglio4 

Ignacio P. Tobia-Gonzalez4 

Alberto M. Jurado4 

Luis Meza-Montoya5 

Carlos H. Scorticati6 

Walter Henriques-da-Costa3 

Juan Yandian7 

Luis Ubillos7 

Sidney Glina8 

Marcos Tobias-Machado8 

Oscar Rodríguez-Faba9 

Carlos Ameri10 

Alejandro Nolazco11 

Pablo Martinez11 

Gustavo Franco Carvalhal12 

Ruben G. Bengio13 

Leandro Cristian Arribillaga13 

Raúl Langenhin14 

Diego Muguruza14 

José G. Campos-Salcedo15 

Edgar I. Bravo-Castro15 

Pablo A. Mingote16 

Nicolás Ginestar16 

Ana M. Autran-Gomez17 

Roberto Puente7 

Ricardo Decia7 

Gustavo Cardoso-Guimarães3 

Joan Palou-Redorta9 

Diego Abreu-Clavijo2 

Stenio de Cassio-Zequi3 

Francisco T. Rodriguez-Covarrubias1  * 

on behalf of the Latin American Renal Cancer Group (LARCG)

1Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico

2Hospital Pasteur, Montevideo, Uruguay

3A.C. Camargo Cancer Center, Sao Paulo, Brazil

4Hospital Italiano, Buenos Aires, Argentina

5Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru

6Hospital de Clínicas, Buenos Aires, Argentina

7Hospital de Clínicas, Montevideo, Uruguay

8Escuela de Medicina ABC, Sao Paulo, Brazil

9Fundación Puigvert, Barcelona, Spain

10Hospital Alemán, Buenos Aires, Argentina

11Hospital Británico, Buenos Aires, Argentina

12School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil

13Clínica Profesor Bengio, Cordoba, Argentina

14Corporación Médica de Paysandú (COMEPA), Paysandu, Uruguay

15Hospital Central Militar, Mexico City, Mexico

16Policlinico Neuquén, Neuquén, Argentina

17Hospital Fundación Jiménez Díaz, Madrid, Spain



The incidence of renal cell carcinoma (RCC) is increasing globally due to an aging population and widespread use of imaging studies.


The aim of this study was to describe the characteristics and perioperative outcomes of RCC surgery in very elderly patients (VEP), ≥ 75 years of age.


This is a retrospective comparative study of 3656 patients who underwent the treatment for RCC from 1990 to 2015 in 28 centers from eight Latin American countries. We compared baseline characteristics as well as clinical and perioperative outcomes according to age groups (<75 vs. ≥75 years). Surgical complications were classified with the Clavien-Dindo score. We performed logistic regression analysis to identify factors associated with perioperative complications.


There were 410 VEP patients (11.2%). On bivariate analysis, VEP had a lower body mass index (p < 0.01) and higher ASA score (ASA >2 in 26.3% vs. 12.4%, p < 0.01). There was no difference in performance status and clinical stage between the study groups. There were no differences in surgical margins, estimated blood loss (EBL), complication, and mortality rates (1.3% vs. 0.4%, p = 0.17). On multivariate regression analysis, age ≥75 years (odds ratio [OR] 2.33, p < 0.01), EBL ≥ 500 cc (OR 3.34, p < 0.01), and > pT2 stage (OR 1.63, p = 0.04) were independently associated with perioperative complications.


Surgical resection of RCC was safe and successful in VEP. Age ≥75 years was independently associated with 30-day perioperative complications. However, the vast majority were low-grade complications. Age alone should not guide decision-making in these patients, and treatment must be tailored according to performance status and severity of comorbidities. (REV INVEST CLIN. 2020;72(5):308-15)

Key words: Kidney cancer; Elderly; Nephrectomy; Latin America; Surgical Complications; Surgical outcomes


Genitourinary malignancies represent a significant public health problem, particularly in developing countries were up to 52% of all genitourinary cancer deaths occur1. In the most recent compilation of data on population-based cancer occurrence, the American Cancer Society estimated that kidney and renal pelvis tumors account for the 6th most common estimated new cancer cases in men (5%) and the 8th in women (3%) in the United States2 The World Health Organization estimated that by 2018, from the total combined cancer data, kidney tumors were responsible for 403,262 (2.2%) estimated new cancer cases and 175,098 (1.8%) cancer deaths in the world. Furthermore, the worldwide age standardized rate (per 100,000 persons per year) for new cases of kidney cancer was 6.0 for men and 3.1 for women, while in low or medium human development index regions, it was 1.8 for men and 1.1 for women3. In addition, it has been recently demonstrated that over the most recent 10-year period, the greatest increase in renal cell carcinoma (RCC) incidence occurred in Central and South America, where the average annual percentage change ranged from 3.0% to 6.8% in men and 2.5% to 6.4% in women4.

Due to increasing life expectancy, the number of incident cases of RCC will continue to grow and an increasing proportion of patients aged 75 or older will be ultimately diagnosed with renal cancer and will be considered for active treatment. Despite technological and pharmacological developments, surgery is the cornerstone for the management of most localized (T1/T2) and locally advanced (T3) tumors. Nonetheless, the benefit of this strategy is unclear for elder patients, particularly for frail individuals at higher risk of surgical complications. Guzzo et al. reported an overall complication rate of 22.6% and 0% mortality rate in a cohort of 115 patients >75 years of age who underwent laparoscopic renal surgery in the United States5.

We have previously described our surgical experience in a small cohort of elderly patients with RCC showing that surgery appears to be safe in properly selected cases6. To the best of our knowledge, larger reports coming from Latin America are scarce. Therefore, our objective was to compare clinical characteristics and perioperative outcomes of patients 75 years or older with their younger counterparts treated surgically for RCC in Latin America.


This is a retrospective comparative study of the database of patients with renal tumors from the Latin American Renal Cancer Group (LARCG)7. It comprised data from 3656 patients who underwent surgery for RCC from 1990 to 2015 in 28 centers from eight Latin American countries. This study was approved by the corresponding Review Board of each institution. For this study, baseline characteristics as well as clinical and perioperative outcomes according to age groups (<75 years vs. ≥75 years) were compared. We arbitrarily defined very elderly patients (VEP) as those 75 years or older due to RCC epidemiology trends. Patients who did not undergo surgical treatment were excluded from this study. Variables analyzed included sex, age, renal function, comorbidities, eastern cooperative oncology group performance status, tumor stage, clinical stage (using the American Joint Committee on Cancer tumor-node-metastasis 8th edition staging system), type of surgery, estimated blood loss (EBL), length of hospital stay (LOS), and perioperative complications8. Surgical complications were classified according to the Clavien-Dindo classification9. Major complications were defined as Clavien-Dindo >II.

Statistical analysis was performed using the SPSS 20.0 for IBM. For descriptive statistics, we used central tendency measures such as mean or median. Standard deviation or interquartile range and range were used as dispersion descriptive measures. Bivariate analysis was performed using paired samples test by t-test while non-parametric variables were compared with Mann–Whitney U-test. Proportions were compared using Chi-square test. Binary logistic regression analysis was performed to identify independent risk factors associated with perioperative outcomes and complications. Any p ≤ 0.05 or 5% were considered as statistically significant for a two-tied distribution.


Baseline patient characteristics between the study groups are summarized in Table 1. Four-hundred and ten patients (11.2%) were ≥75 years old compared to 3246 (88.8%) patients who were <75 years old. The median follow-up was 21.4 months. On bivariate analysis, patients <75 years had a higher body mass index and had more active smokers. On the other hand, older patients ≥75 years had more hypertension and a higher ASA score. There were no differences in signs and symptoms at diagnosis and performance status between the study groups.

Table 1 Baseline characteristics between the study groups 

<75 year old (%) ≥75 (%) p-value
Sex 0.99
Male 2121 (65.4) 268 (65.4)
Female 1123 (34.6) 142 (34.6)
BMI (kg/m2) 28.1 ± 5.4 26.7 ± 4.2 0.01
Smoking status 0.01
Active smoker 228 (11.3) 25 (8.7)
Ex-smoker 699 (34.7) 76 (26.7)
Non-smoker 1087 (54) 184 (64.6)
Hypertension <0.01
Yes 436 (13.4) 91 (22.2)
No 2810 (86.6) 319 (77.8)
ECOG 0.12
ECOG 0-1 1822 (96.2) 246 (94.3)
ECOG >1 71 (3.8) 15 (5.7)
ASA 0.01
ASA 1-2 2263 (84.2) 232 (64.8)
ASA >2 426 (15.8) 126 (35.2)
Signs and symptoms at diagnosis 0.78
Yes 1667 (61.6) 218 (60.9)
No 1037 (38.4) 140 (39.1)
Clinical stage 0.57
CS I 1234 (60.5) 151 (59)
CS II 324 (15.9) 42 (16.4)
CS III 328 (16.1) 48 (18.8)
CS IV 154 (7.5) 15 (5.8)

BMI: body mass index; ECOG: Eastern Cooperative Oncology Group.

There were no differences regarding clinical stage, pT stage, pathologic tumor size, Fuhrman grade, multifocality, pN, or pM between the study groups (Table 2). However, clear cell histology was far more frequent in the VEP (65.4% vs. 55%, p < 0.01). Tumor complexity assessment information was not the focus of our study and was not analyzed.

Table 2 Comparison of pathological characteristics between the study groups 

<75 year old (%) ≥75 (%) p-value
Histology 0.01
Clear cell 1785 (55) 268 (65.4)
Other 1461 (45) 142 (34.6)
Fuhrman 0.95
Low grade 1359 (66.8) 184 (66.7)
High grade 674 (33.2) 92 (33.3)
pT stage 0.20
pT1-T2 2142 (79.8) 266 (76.9)
pT3-T4 541 (20.2) 80 (23.1)
pTumor size (cm) 5.0 ± 4.7 5.2 ± 4.5 0.33
Multifocality 0.42
Yes 130 (5.1) 23 (6.5)
No 2477 (94.9) 331 (93.5)
pN 0.78
pN0 1710 (94.5) 208 (95)
pN1 99 (5.5) 11 (5.0)
pM 0.99
pM0 1670 (90.8) 216 (90.8)
pM1 170 (9.2) 22 (9.2)

The laparoscopic approach (44.4% vs. 37.4%, p < 0.02) and radical nephrectomy (72.2% vs. 57.9%, p < 0.01) were far more commonly performed in VEP. Surgical and perioperative characteristics are listed in Table 3. There were no differences in surgical margin status, lymph node dissection, EBL, and complication rates. Major complication rates, defined as Clavien-Dindo Grade >II, were also similar between the study groups (5.0% vs. 4.2% in VEP, p = 0.59). Perioperative mortality was also similar between the study groups (0.4% vs. 1.4% in VEP, p = 0.85). LOS was slightly longer in older patients (4 ± 4 vs. 4 ± 3 days, p < 0.01). Subgroup analysis among patients treated with partial nephrectomy was performed, and no differences were observed with regard to total complication rates between the study groups (p = 0.99, Table 4). No perioperative deaths were registered among those 75 years or older who underwent partial nephrectomy.

Table 3 Surgical and perioperative characteristics between the study groups 

<75 year old (%) ≥75 (%) p-value
Surgical approach 0.02
Laparoscopic 1164 (37.4) 176 (44.5)
RALP 24 (0.7) 4 (1.0)
Open 1927 (61.9) 216 (54.5)
Primary tumor treatment 0.01
Radical nephrectomy 1878 (57.9) 296 (72.2)
Partial nephrectomy 1368 (42.1) 114 (27.8)
Surgical time (min) 174 ± 88 164 ± 75 0.01
EBL (mL) 455 ± 675 416 ± 473 0.37
Surgical margins 0.77
Positive 102 (3.4) 12 (3.1)
Negative 2885 (96.6) 371 (96.9)
Blood transfusion 0.28
Yes 455 (17.5) 66 (19.9)
No 2140 (82.5) 265 (80.1)
Lymphadenectomy 0.06
Yes 532 (19.1) 47 (12.9)
No 2250 (80.9) 318 (87.1)
Clavien-Dindo 0.17
None 572 (43.7) 96 (44.7)
Clavien I-II 670 (51.2) 110 (51.2)
Clavien III-IV 61 (4.7) 6 (2.8)
Clavien V 5 (0.4) 3 (1.3)
Length of stay (days) 4 ± 3 4 ± 4 0.01

EBL: estimated blood loss.

Table 4 Comparison of complication rates following partial nephrectomy between the study groups 

Clavien-Dindo <75 year old (%) ≥75 (%) p-value
None 200 (45.1) 20 (45.5) 0.99
Clavien I-II 222 (50.1) 22 (50.0)
Clavien III-IV 20 (4.6) 2 (4.5)
Clavien V 1 (0.2) 0 (0)

On our multivariate logistic regression analysis, EBL ≥500 cc (odds ratio [OR] 3.34, CI 2.23-4.99), age ≥ 75 years (OR 2.33, CI 1.29-4.21), open surgery (OR 2.52, CI 1.70-3.77), and > pT2 stage (OR 1.63, CI 1.02-2.59, p < 0.04) were associated with 30-day perioperative complications following surgical treatment for RCC (Table 5).

Table 5 Independent risk factors for 30-day perioperative complications following primary treatment 

Variable OR CI p-value
Age ≥75 years 1.05 0.77-1.42 0.75
EBL ≥500 5.33 4.07-6.97 0.01
BMI ≥30 kg/m2 1.44 1.04-1.98 0.03
Partial nephrectomy* 0.85 0.68-1.05 0.13
> pT2 stage 1.89 1.44-2.47 0.01
Open Surgery** 1.67 1.34-2.08 0.01
Age ≥75 years 2.33 1.29-4.21 0.01
EBL ≥500 3.34 2.23-4.98 <0.01
BMI ≥30 kg/m2 1.50 0.97-2.3 0.07
> pT2 stage 1.63 1.02-2.59 0.04
Open surgery** 2.52 1.70-3.77 <0.01

*Radical nephrectomy.

**Minimally invasive surgery. EBL: estimated blood loss; OR: odds ratio; BMI: body mass index.


In the past decade, an increase in the incidence of RCC has been detected in most countries, particularly in Latin American populations for both men and women4. This is probably due to the widespread use of abdominal imaging studies for other diagnostic purposes. Nevertheless, while mortality trends have been steady or declining in high-income countries, they have remained unchanged or even increased in Latin America4.

Although the treatment of choice for localized renal masses should be individualized, surgical resection (including nephron-sparing surgery [NSS]) is still considered the standard of care for organ-confined disease10. In experienced hands, NSS is an excellent alternative for patients with small renal masses (SRM), with oncological equivalence and better preservation of renal function when compared to radical nephrectomy11.

Active surveillance (AS) for SRM has gained popularity worldwide since large cohorts have demonstrated that adherent patients have low risk of metastasis (1–2%) at a median of 2-year follow-up12. These results are encouraging and AS must be considered an alternative in the VEP that is a poor surgical candidate.

Nonetheless, the optimal treatment option in the VEP is debatable, to say the least. An adequate general and geriatric evaluation by a multidisciplinary team may provide additional insight for deciding the optimal treatment in this patient population13. A large retrospective study of 537 patients demonstrated that active treatment in patients aged ≥75 years with clinical T1 renal cancer was not associated with improved overall survival and that nephrectomy accelerated renal dysfunction14. A recent study of 115 octogenarian patients observed no differences in survival between AS, NSS, and radical nephrectomy for SRM15. However, AS may be inadequate in healthy elderly patients and surgical resection should always be considered in selected individuals because at least 20% of SRM are considered to be potentially aggressive cancers16.

Despite the previous findings, the surgical modality of choice (RN vs. NSS) for localized renal masses in elderly patient is still unclear. In this study, we observed that while patients 75 years or older had higher ASA scores (ASA >2) and larger tumors, they did not have higher 30-day total complication rate. A recent study where a propensity score analysis of surgical, functional, and oncologic outcomes was performed between 613 patients over 75 years of age compared to matched controls who underwent partial versus radical nephrectomy, found that partial nephrectomy in elderly patients with localized tumors did not compromise oncologic outcomes and allowed better functional preservation compared to radical nephrectomy during a 3-year follow-up. However, they reported a higher overall complication rate in the partial nephrectomy group (33% vs. 25%, p = 0.01)17. In our study, partial nephrectomy was performed less commonly in older patients and, on subgroup analysis, there were no differences in complication rates between the study groups. Moreover, long-term renal function was not analyzed in our database. The laparoscopic approach was more common in this subgroup, with no differences in EBL and blood transfusion rates. Surgical time was shorter in VEP, and a possible explanation for this is that more patients underwent radical nephrectomy. On the other hand, LOS was slightly higher in VEP (p < 0.01). Interestingly, in our bivariate analysis, VEP did not have greater perioperative complications; however, in our sparse multivariate model, the variables associated with 30-day perioperative complications (Clavien-Dindo Grade I-V) following surgery were EBL ≥500 cc, open surgery, age ≥75 years, and > pT2 stage. Of greater importance, in our multivariate logistic regression analysis, age ≥75 years was not associated (OR 1.22, CI 0.60-2.48, p = 0.59) with greater major complications (Clavien-Dindo >II).

The main limitations of this study are its retrospective nature and the missing data that are intrinsic to multicenter databases such as LARCG. LARCG, however, is the first Latin American effort to create a multinational patient database for patients with RCC, and we believe that these results are clinically useful in our population. Larger prospective studies should be conducted to further address this issue.

The higher perioperative complication rates and the fact that renal function benefit after NSS is seen throughout many years of follow-up may make this surgical approach for elderly patient unappealing to some surgeons, and this is possibly the reason more of these patients were treated with radical nephrectomy in our cohort. However, our data suggest that there is no difference in perioperative complication rates of NSS between the study groups. An et al. reported similar perioperative outcomes and further demonstrated that NSS was associated with better preservation of renal function and equivalent overall and cancer-specific survival between modalities18. Thus, in countries, where there is limited experience with minimally invasive ablative techniques or if clinical follow-up may be a concern, we recommend surgical resection (NSS in experienced hands) as primary treatment in physically fit elderly patients.

Surgical resection of RCC is safe and successful in properly selected VEPs. Age ≥75 years was an independent risk factor associated with any 30-day perioperative complications following surgical treatment for RCC. However, perioperative outcomes, most importantly major complication and mortality rates, are similar to their younger counterparts. Age alone should not guide decision making in these patients, and treatment must be tailored according to performance status and severity of other comorbidities.


The authors would like to thank Dr. Carolina Cauduro and Dr. Pablo M. Barrios from Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), School of Medicine, Porto Alegre, Brazil, for their support in recollecting data.

These results were presented at the American Urological Association’s (AUA) 2018 Annual Meeting in San Francisco, California.

This is a retrospective study of a large database of patients from Latin America. This study was IRB approved at each institution.


1. Greiman AK, Rosoff JS, Prasad SM. Association of human development index with global bladder, kidney, prostate and testis cancer incidence and mortality. BJU Int. 2017;120:799-807. [ Links ]

2. Sieger R, Miller K, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70:7-30. [ Links ]

3. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018:globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68:394-424. [ Links ]

4. Znaor A, Lortet-Tieulent J, Laversanne M, Jemal A, Bray F. International variations and trends in renal cell carcinoma incidence and mortality. Eur Urol. 2015;67:519-30. [ Links ]

5. Guzzo TJ, Allaf ME, Pierorazio PM, Miller D, McNeil BK, Kavoussi LR, et al. Perioperative outcomes of elderly patients undergoing laparoscopic renal procedures. Urology. 2009;73:572-6. [ Links ]

6. Rodríguez-Covarrubias F, Rivera-Ramirez JA, Gabilondo-Pliego B, Castillejos-Molina RA, Sotomayor M, Feria-Bernal G, et al. Tratamiento quirúrgico del carcinoma de células renales en personas de edad avanzada. Actas Urol Esp. 2016;40:395-9. [ Links ]

7. Zequi SC, Clavijo DA. The creation, development and diffusion of the LARCG-Latin American renal cancer group. Int Braz J Urol. 2017;43:3-6. [ Links ]

8. Amin MB, Greene ES, Byrd DR, Brookland RK, Washington MK, Gershenwald JE, et al. AJCC Cancer Staging Manual. 8th ed. Berlin:Springer;2017. [ Links ]

9. Dindo D, Demartines N, Clavien PA. 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. [ Links ]

10. Van Poppel H, Becker F, Cadeddu JA, Gill IS, Janetschek G, Jewett M, et al. Treatment of localised renal cell carcinoma. Eur Urol. 2011;60:662-72. [ Links ]

11. Volpe A, Jewett M. The natural history of small renal masses. Nat Clin Pract Urol. 2005;2:384-90. [ Links ]

12. Ristau BT, Correa AF, Uzzo RG, Smaldone MC. Active surveillance for the small renal mass:growth kinetics and oncologic outcomes. Urol Clin North Am. 2017;44:213-22. [ Links ]

13. Droz JP, Boyle H, Albrand G, Mottet N, Puts M. Role of geriatric oncologists in optimizing care of urological oncology patients. Eur Urol Focus. 2017;3:385-94. [ Links ]

14. Lane BR, Abouassaly R, Gao T, Weight CJ, Hernandez AV, Larson BT, et al. Active treatment of localized renal tumors may not impact overall survival in patients aged 75 years or older. Cancer. 2010;116:3119-26. [ Links ]

15. Tang DH, Nawlo J, Chipollini J, Gilbert SM, Poch M, Pow-Sang JM, et al. Management of renal masses in an octogenarian cohort:is there a right approach?Clin Genitourin Cancer. 2017;15:696-703. [ Links ]

16. Mirza M. Management of small renal masses in the older adult. Clin Geriatr Med. 2015;31:603-13. [ Links ]

17. Mir MC, Pavan N, Capitanio U, Antonelli A, Derweesh I, Rodriguez-Faba O, et al. Partial versus radical nephrectomy in very elderly patients:a propensity score analysis of surgical, functional and oncologic outcomes (RESURGE project). World J Urol. 2020;38:151-8. [ Links ]

18. An JY, Ball MW, Gorin MA, Hong JJ, Johnson MJ, Pavlovich CP, et al. Partial versus radical nephrectomy for T1-T2 renal masses in the elderly:comparison of complications, renal function, and oncologic outcomes. Urology. 2017;100:151-7. [ Links ]

Received: February 06, 2020; Accepted: April 10, 2020

* Corresponding author: Francisco T. Rodriguez-Covarrubias E-mail:

Creative Commons License Instituto Nacional de Cardiología Ignacio Chávez. Published by Permanyer. This is an open ccess article under the CC BY-NC-ND license