Long-Term Oncologic Outcomes of Off-Clamp Robotic Partial Nephrectomy for Cystic Renal Tumors: A Propensity Score Matched-Pair Comparison of Cystic versus Pure Clear Cell Carcinoma

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This study was reported the oncological outcomes in patients with cystic RCC who underwent RAPN. The reviewer would like to suggest some critiques as follows.

1.      On line 15 et al., what is “pure ccRCC”? The authors should provide a definition in this regard.

2.      On line 25 et al., is “10-yr” correct? “10-year” is better.

3.      On line 37 et al., the authors should correct unnecessary spaces.

4.      On line 103, what is “complete biochemical blood tests”?

5.      On line 108, “RENAL score” is correct? R.E.N.A.L. nephrometry score? Reference should also be provided.

6.      On line 123 et al., abbreviation should be used correctly.

7.      On Table 1, what are PS, SD, M, F, and N?

8.      The number of references is less than the submission rule and needs to be revised.

Author Response

This study was reported the oncological outcomes in patients with cystic RCC who underwent RAPN. The reviewer would like to suggest some critiques as follows.

1. On line 15 et al., what is “pure ccRCC”? The authors should provide a definition in this regard.

• We thank the Reviewer for reading our article and for suggesting improvements.

We referred to "pure ccRCC" to emphasize a clear cell renal carcinoma without any cystic differentiation at pathologic examination. The manuscript was updated accordingly to clarify this defintion.

Manuscript (page 2, line 59): “There are few studies showing oncological outcomes of cystRCC compared to “pure” ccRCC, defined as tumor without any cystic differentiation at pathologic examination. Additionally, there is limited data available with a long-term follow-up [9,10].”

2. On line 25 et al., is “10-yr” correct? “10-year” is better.

• The main text was edited as follows:
  

Abstract (page 1, line 25): “Comparable 10-year cancer specific survival probability (95.3% versus 100%, p=0.146) was found between the two cohorts.”

3. On line 37 et al., the authors should correct unnecessary spaces.

• The main text has been updated:

Manuscript (page 1, line 36): “Renal Cell Carcinoma (RCC) represents about three percent of all forms of cancer and about 90% of malignant lesions of the kidney. The three primary types of RCC are clear cell RCC (ccRCC), papillary RCC (pRCC) and chromophobe RCC (chRCC) (representing up to 70-85%, 10-15%, and 4-5% of cases, respectively).”

4. On line 103, what is “complete biochemical blood tests”?

• We clarified the sentence.

Manuscript (page 3, line 117): “Follow-up visits encompassed complete biochemical blood tests, including serum creatinine, electrolyte levels, urea nitrogen and uric acid.”

5. On line 108, “RENAL score” is correct? R.E.N.A.L. nephrometry score? Reference should also be provided.

• We mean R.E.N.A.L. nephrometry score. The proper reference has been added.

Manuscript (page 3, line 123): “The main clinical features were compared for the two groups. A 1:3 PSM analysis was used to obtain two populations homogeneous for age, gender, tumor size, R.E.N.A.L. nephometry score, pT stage and Fuhrman Grade to decrease covariate imbalance to < 10%. Continuous data were presented as median and interquartile ranges (IQR), while frequencies and pro-portions were used for categorical variables. Student-t and Chi-Square tests were employed to compare continuous and categorical variables, respectively.”

6. On line 123 et al., abbreviation should be used correctly.

• - The text has been updated.

7. On Table 1, what are PS, SD, M, F, and N?

• We appreciate your annotation. The caption has been updated:

Manuscript (Page 5, line 168): “Table 1. Clinical and pathologic data of the whole cohort and after the Propensity Score (PS) Matched Analysis

SD: Standard Deviation; M: male; F: female; N: number.”

8. The number of references is less than the submission rule and needs to be revised.

• We thank the Reviewer for the comment.

     According to submission rules, there is not a minimum of References:

“References must be numbered in order of appearance in the text (including citations in tables and legends) and listed individually at the end of the manuscript. We recommend preparing the references with a bibliography software package, such as EndNote, ReferenceManager or Zotero to avoid typing mistakes and duplicated references. Include the digital object identifier (DOI) for all references where available. Citations and references in the Supplementary Material are permitted provided that they also appear in the reference list here. In the text, reference numbers should be placed in square brackets [ ], and placed before the punctuation; for example [1], [1–3] or [1,3]. For embedded citations in the text with pagination, use both parentheses and brackets to indicate the reference number and page numbers; for example [5] (p. 10), or [6] (pp. 101–105).”

However, references number was increased.

Reviewer 2 Report

Comments and Suggestions for Authors

The paper presents a comprehensive and pioneering study on the long-term oncological outcomes of cystic renal cell carcinoma (cystRCC) compared to pure clear cell renal cell carcinoma (ccRCC) following off-clamp robotic partial nephrectomy (off-C RPN). The authors have meticulously conducted a propensity score-matched (PSM) analysis to minimize covariate imbalance and ensure the comparability of the two cohorts. This study is significant as it fills a gap in the current data on the survival outcomes of partial nephrectomy performed for cystic renal tumors, which has been previously underexplored. However, there are a few areas for improvement:

1)  If the authors utilized an internal renal cancer database, clarification is needed on how the specified patients' written consent information was obtained.

2) Although the study design is generally comprehensible, it is advisable to include its clear statement, exclusion criteria, and the study timeframe in the Methods section. Additionally, the inclusion of a flowchart diagram could visually depict the study details and the number of patients before and after PSM.

3) Although the surgical technique employed is briefly described, a more detailed discussion on how variations in surgical technique might impact oncological outcomes would be beneficial.

4)   Please review the Statistical subsection to include an explanation of how the data presented in Table 1, expressed as Median (Interquartile Range), was compared. Additionally, the subsection lacks data regarding the Kaplan-Meier analysis provided in the Results section.

5)   The study focuses on tumor histology as a predictor of disease progression. However, comorbidities can significantly influence long-term outcomes following off-C RPN. Therefore, it's recommended to either provide an explanation of comorbidities in Table 1 or explicitly address this potential bias in the limitations section.

6)   The authors may consider including supplementary clinical data to provide a more holistic view of the patient cohorts. For example, information on preoperative comorbidities, kidney function, perioperative complications, and postoperative management protocols could explain the clinical characteristics of the study population and enhance the clinical relevance of the findings.

7)    Ensure that Table 1 is referenced in the text.

Comments on the Quality of English Language

Attention to minor grammatical and typographical errors is recommended before final publication.

Author Response

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

None.