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.