JU INSIGHT Extended Lymph Node Sampling During Surgery for Pediatric Renal Tumors and Postoperative Complication Rates

By: Jonathan P. Walker, MD*, Atrium Health Levine Children’s Hospital, Charlotte, North Carolina; Daniel S. Han, MD*, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California; Andrew Nicklawsky, MS, University of Colorado Cancer Center, Aurora; Peter Boxley, MD, University of Colorado School of Medicine, Children’s Hospital of Colorado, Aurora; Jeffery Morrison, MD, University of Colorado School of Medicine, Children’s Hospital of Colorado, Aurora; Michael Tonzi, MD, University of Tennessee College of Medicine Chattanooga; Jennifer Bruny, MD, University of Colorado School of Medicine, Children’s Hospital of Colorado, Aurora; Jonathan P. Roach, MD, University of Colorado School of Medicine, Children’s Hospital of Colorado, Aurora; Nicholas G. Cost, MD, University of Colorado School of Medicine, Children’s Hospital of Colorado, Aurora; * Co-first authors. | Posted on: 27 Jun 2023

Walker JP, Han DS, Nicklawsky A, et al. Extended lymph node sampling during surgery for pediatric renal tumors concerning for malignancy does not increase postoperative complication rates. J Urol. 2023;209(6):1186-1193.

Study Need and Importance

Lymph node sampling (LNS) is a requirement during the removal of a suspected malignant renal mass in children, but no standardized LNS template exists. Unfortunately, LNS is often omitted or low yield, which can impact staging accuracy and treatment paradigms. Suggestions to formalize an LNS template during the surgery for pediatric renal tumors in order to increase protocol compliance and lymph node yield (LNY) have been met with concerns over also increasing the likelihood of having a surgical complication.

We hypothesized that higher LNY would not be associated with an increase in clinically significant complications. Our aim was to demonstrate the safety of a more extensive LNS during extirpative renal tumor surgery in the pediatric population.

What We Found

At our institution, in patients 0-18 years old undergoing surgery with LNS for a suspected renal malignancy, major postoperative complications were rare (15%) and there was no relationship between LNY and clinically significant complications 5 months postoperatively (P = .6; see Table and Figure).

Figure. Example of lymph node sampling templates for right- and left-sided pediatric renal tumors. Right, peri-hilar, para-caval, and interaortocaval lymph node packets. Left, peri-hilar, para-aortic, and interaortocaval lymph node packets. Blue star indicates aorta; yellow star, IVC; green star, common iliac artery.

Table. Multivariable Logistic Regression Model of Select Variables on Clinically Significant Surgical Complications

Parameter	Odds ratio (95% CI)	P value
No. LNs (continuous)	0.98 (0.93, 1.04)	.6
Intraoperative fluid volume, cc	1.00 (1.00, 1.00)	.01
Abbreviations: CI, confidence interval; LN, lymph node.

Limitations

This study was retrospective in nature and may have suffered from incomplete data and/or loss to follow-up. We believe those limitations were minimized due to the geographically isolated position of our institution, which should make it less likely that patients would seek care at other facilities, especially for major complications. Since our data were collected from a single, high-volume institution, the results may not be generalizable to smaller-volume centers.

Interpretation for Patient Care

We hope that our results will encourage more research into the use of a standardized LNS template and its effect on protocol adherence, staging accuracy, LNY, and event-free and overall survival in pediatric patients with malignant renal tumors.