DISCUSSION
RCC is more common in males than in females.1 In our study, 63.5% of the patients were male and 36.5% were female, which was consistent with the literature. RCC is especially common among the 60-70 age group.3 The mean age of our patients was 59.68±12.54 years, which was similar to the literature.
More than 50-60% of RCCs are detected incidentally in USG evaluation for other reasons.2,3 Incidental RCC was detected in 48.4% of the patients in our study. The rate of Stage 1 RCC according to TNM staging Chang et al. found 54.9%, while Chen et al. they found it to be 69.8%.10,11 As a result of the increased use of USG and CT over the years, it is expected that the incidence of incidental diagnosis will increase, which in turn increases the incidence of early-stage RCC. In our study, since the number of patients diagnosed incidentally (48.4%) were lower than expected, the rate of stage 1 RCC (54.5%) was also lower compared to other stages.
During the pandemic, active monitoring was recommended at 6-12 month intervals for kidney tumors masses below 4 cm. Patients with more advanced renal tumors such as T2, T3, or T4 should be evaluated carefully as they are at risk of metastasis. Early treatment should be preferred if there are imaging findings showing aggressive features and if a renal biopsy has been performed and aggressive features were detected.12 Lei et al. reported that the mortality rate of asymptomatic patients who tested positive for COVID-19 after surgery was 20%.13 On the other hand, in another study conducted during the COVID-19 pandemic, it was reported that surgical procedures can be performed safely without the development of COVID-19-related mortality if adequate precautions are taken.14
RCC consists of a heterogeneous group of diseases. While treatment of some RCC tumors that do not show aggressive features can be safely postponed, treatment of RCC with aggressive features should be given a priority. Therefore, a risk-based approach should be made for patients with RCC during the pandemic. 15 In our study, 297 (65%) patients were operated for RCC in the 1-year period before COVID-19, and 160 (35%) were operated in the 1-year period during COVID-19. The number of surgeries for RCC during the COVID-19 period have decreased drastically.
The classic symptom triad, which presents as gross hematuria, palpable abdominal mass, and flank pain, is rarely seen in RCC. However, hematuria is an important finding in terms of diagnosis and treatment.3 Lee et al. reported that patients with symptomatic findings such as pain and hematuria showed aggressive histology and a worse prognosis.16 In our study, although there was no significant difference in terms of admission complaints between two study periods, the rate of patients presenting with hematuria was found to be higher in the COVID-19 period compared to the pre-COVID-19 period (14.4% vs. 9.8%). Although patients can neglect or delay seeking medical help for pain, hematuria is a finding that is noticed by the patient and urges them to seek medical attention. Therefore, we found that the rate of admission due to hematuria increased during the COVID-19 period.
In their study comparing the COVID-19 period to the same period before the pandemic, Srivastava et al. reported that postponing surgery for 3 or more months after diagnosis did not increase the risk of tumor progression and tumor size in localized RCC.17 In our study, while the mean time between diagnosis and surgery was 40.3±34.9 days in the pre-COVID-19 period, it was 55.98±51.02 days during the COVID-19 period, and this difference between the two groups was significant. However, there was no significant difference in pathological tumor sizes and tumor stages between two periods.
In the review by Simone et al., they suggested that open surgery should be preferred instead of laparoscopy if adequate precautions cannot be taken in terms of the risk of airborne transmission during the COVID-19 pandemic.18 To our knowledge, there are no studies comparing open surgery to laparoscopic surgery in terms of possibility of transmission of a virus during the operation. The recommendation for open surgery over laparoscopy is based solely on expert opinion.19 In our study, there was no difference in open and laparoscopic surgery rates between the two study periods.
Although there is an increase in early diagnosis of RCC, metastasis is detected at the time of initial diagnosis in almost one third of patients.20 It should be kept in mind that as the RCC tumor size increases, the possibilities of detecting metastases and the development of metastases in the future are higher.21In localized RCC, after a surgical treatment, metastases are detected in 30% of patients in the later stages.22 In our study, there was no significant difference between pre-COVID-19 period and the COVID-19 period in terms of tumor sizes in the imaging. Metastasis was not detected in 418 (91.5%) patients in the imaging methods performed at the time of diagnosis. However, distant organ metastases were detected in 39 (8.5%) patients. There was a significant difference between two study periods in terms of metastases detected in the pre-operative imaging (21 (13.1%) vs 18 (6.1%) patients, in groups 1 and 2, respectively). Although the numerical values ​​of metastatic patients were close to each other in both study periods, the rate of metastatic patients was higher in the COVID-19 study period due to the lower number of operated patients in that period. We think that this is because patients applied due to metastasis-related symptoms.
In their study of RCCs smaller than 4 cm Uzosike et al. found that the mean tumor size increased by 0.09 cm per year during delayed treatment in RCC. They also reported that the increase was 0.54 cm in the group followed for less than 6 months, 0.07 cm in the group followed for more than 1 year. Moreover, no metastatic disease developed in any patient, no significant difference was found in growth rates, and the variability of tumor growth rates decreased over time.23 In Uzosike et al.’s study, the tumor sizes increased more in the group of patients followed for less than 6 months, and therefore, earlier surgery was performed instead of follow-up in these rapidly growing tumors, therefore we believe that their grouping was not homogeneous. Doughtery et al. found the rate of metastasis at the time of diagnosis to be 4% in RCC below 5 cm. They reported that tumor size is the main factor in decision making, but the risk of metastasis is different for each mass depending on the tumor histology.24 Kim et al. compared waiting periods of less than 3 months and less than 1 month in RCC over 7 cm and concluded that there was no difference between the two groups in terms of overall survival and disease-related survival. Although it was not significant, they found the pathological upstage to be higher in the group with a longer waiting period. However, they excluded patients who waited longer than 3 months.25In the literature, most studies were retrospective and clinicians seem to be more selective and turn to early surgery for RCC patients who appear to have more aggressive and fast-growing tumors.