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Background Predicting oncologic outcomes is important for patient counseling, clinical trial design, and biomarker study testing. Objective To develop prognostic models for progression-free (PFS) and cancer-specific survival (CSS) in patients with clear cell renal cell carcinoma (ccRCC), papillary RCC (papRCC), and chromophobe RCC (chrRCC). Design, setting, and participants Retrospective cohort review of the Mayo Clinic Nephrectomy registry from 1980 to 2010, for patients with nonmetastatic ccRCC, papRCC, and chrRCC. Intervention Partial or radical nephrectomy. Outcome measurements and statistical analysis PFS and CSS from date of surgery. Multivariable Cox proportional hazards regression was used to develop parsimonious models based on clinicopathologic features to predict oncologic outcomes and were evaluated with c-indexes. Models were converted into risk scores/groupings and used to predict PFS and CSS rates after accounting for competing risks. Results and limitations A total of 3633 patients were identified, of whom 2726 (75%) had ccRCC, 607 (17%) had papRCC, and 222 (6%) had chrRCC. Models were generated for each histologic subtype and a risk score/grouping was developed for each subtype and outcome (PFS/CSS). For PFS, the c-indexes were 0.83, 0.77, and 0.78 for ccRCC, papRCC, and chrRCC, respectively. For CSS, c-indexes were 0.86 and 0.83 for ccRCC and papRCC. Due to only 22 deaths from RCC, we did not assess a multivariable model for chrRCC. Limitations include the single institution study, lack of external validation, and its retrospective nature. Conclusions Using a large institutional experience, we generated specific prognostic models for oncologic outcomes in ccRCC, papRCC, and chrRCC that rely on features previously shown—and validated—to be associated with survival. These updated models should inform patient prognosis, biomarker design, and clinical trial enrollment. Patient summary We identified routinely available clinical and pathologic features that can accurately predict progression and death from renal cell carcinoma following surgery. These updated models should inform patient prognosis, biomarker design, and clinical trial enrollment. [ABSTRACT FROM AUTHOR]

Purpose: Although the role of lymph node dissection (LND) is well defined in many urological settings, uncertainty regarding need for LND still exists for patients with renal cell carcinoma (RCC). The aim of the current review is to highlight the rationale for performing or omitting LND at the time of renal surgery. Methods: Data were identified through a search of PubMed and Web of Science, including studies published in the last 20 years in core clinical journals. The review is based on evidence synthesis from a peer-review process of the two authors after a structured data search. Results: Neither imaging, nor predictive tools or molecular/genetic markers accurately identify which patients may warrant a LND. In patients with clinical T1abN0 and absence of unfavorable clinical and pathological characteristics, LND does not appear to offer benefit in terms of staging and cancer control. Conversely, LND can be considered in selected cases (larger tumors, locally advanced diseases or when unfavorable pathological characteristics are likely, as high Fuhrman grade, sarcomatoid features or tumor necrosis) due to the non-negligible risk of associated nodal metastases and possible benefit in terms of cancer control. Conclusions: Although LND does not provide any benefit in the majority of RCC cases (mainly T1abN0M0 cases), it remains an important consideration in intermediate-/high-risk patients for staging purposes, given an increased risk of LNI, and for potential benefit in terms of cancer control. Additional data are urgently needed to improve the accuracy of nodal staging tools and to evaluate the potential role of salvage LND. [ABSTRACT FROM AUTHOR]

To update our experience and report on features predictive of high-quality urology residents at the time of the urology match, because data predicting which medical students will mature into excellent urology residents are sparse. We reviewed our experience with 84 urology residents who graduated from 2006 to 2023. Residents were independently scored 1-10 based on overall quality by the current and former Program Director. Discrepant scoring by >2 was resolved by an independent review. Associations of features from the medical student application with an excellent score (defined as 8-10) were evaluated with logistic regression. Discrepant scoring >2 was noted in only 5 (6%) residents. Among the 84 residents, the median overall score was 7 (range 1-10) and 36 (43%) residents had an excellent score of 8-10. Univariably, higher USMLE step II score (P =.03), election to alpha omega alpha (P =.004), no negative interview comments (P =.002), honors in OB/Gyn (P =.048) and psychiatry clerkships (P =.04), and honors in all core clinical clerkships (P <.001) were significantly associated with an excellent score. In a multivariable model, no negative interview comments (P =.003) and honors in all core clinical clerkships (P =.001) were independently associated with an excellent score (c-index 0.76). There were several notable features (sex, letters of recommendation, USMLE step I, externship at our institution, surgery clerkship grade, and rank list) that were not significantly associated with excellent residents. We demonstrate features associated with excellent urology residents, most notably no negative interview comments and an honors grade in all core clinical clerkships. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Postoperative complications for open radical nephrectomy ( ORN), laparoscopic radical nephrectomy ( LRN), and open partial nephrectomy ( OPN) and its relationship with hospitalisation costs and mortality remain poorly described., The present population-based study suggests modest differences in postoperative complications estimated at 27%, 23%, and 24% among patients with kidney cancer undergoing ORN, LRN, and OPN, respectively. Moreover, postoperative complications were associated with higher mortality, length of stay and total costs of hospitalisation., Objectives The association of complications after renal surgery for renal cell carcinoma ( RCC) with in-hospital mortality and costs remains to be defined., To describe the incidence of complications after open radical nephrectomy ( ORN), laparoscopic RN ( LRN), and open partial nephrectomy ( OPN); and to evaluate its relationship with in-hospital mortality and total costs., Patients and Methods We identified 49 983 individuals who underwent ORN (35 712), LRN (5327), or OPN (8944) for RCC at 2037 hospitals from the Nationwide Inpatient Sample 2001-2008., The outcomes assessed were in-hospital mortality and total hospitalisation costs., Multivariable logistic regression and generalised estimating equations were used to test the associations between complications and in-hospital mortality and total costs., Results With 26.0% of patients experiencing postoperative complications, there were modest differences in the proportion of patients with complications after ORN, LRN, and OPN at 27.0%, 22.6%, and 24.0%, respectively ( P < 0.001)., After adjusting for patient and hospital variables, postoperative complications resulted in higher odds of in-hospital death for ORN (odds ratio [ OR] 7.20; P < 0.001), LRN ( OR 12.04; P < 0.001), and OPN ( OR 7.82; P < 0.001)., Adjusted total costs also rose significantly with the presence of any postoperative complications compared with those without any complications for ORN ($21 242 vs $13 183; P < 0.001), LRN ($19 548 vs $12 555; P < 0.001), and OPN ($18 883 vs $12 098; P < 0.001)., Conclusions With about a quarter of patients experiencing postoperative complications, adverse events for ORN, LRN, and OPN carry a significant risk of in-hospital death and higher total costs., Efforts to reduce postoperative complications may correlate with substantial reductions in hospital mortality and total costs. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether preoperative laboratory values are independently associated with death from clinically confined clear cell renal cell carcinoma (RCC) after radical nephrectomy. Methods: We identified 1707 patients with clinically confined (pNx/pN0, pM0), unilateral, sporadic clear cell RCC treated with radical nephrectomy between 1970 and 2002. Associations of abnormal preoperative laboratory values including hypercalcemia, anemia, elevated erythrocyte sedimentation rate (ESR), and elevated alkaline phosphatase with death from RCC were evaluated using Cox proportional hazards regression models, both univariately and multivariately by adjusting for known prognostic features of the 2002 primary tumor classification, tumor size, nuclear grade, and coagulative tumor necrosis. Results: At last follow-up, 1009 patients had died, including 425 who died from RCC at a median of 3.0 years after surgery (range, 0 to 26 years). Even after adjusting for known prognostic features, 9% of patients with preoperative hypercalcemia exhibited significantly increased likelihood of dying from RCC compared with patients with normal or lower levels of serum calcium (relative ration [RR] 1.64; P = 0.002). Similarly, preoperative anemia (35% of patients; RR 1.27; P = 0.026) and elevated ESR (44% of patients; RR 1.66; P = 0.003) portended an increased risk of death from RCC even after multivariate adjustment. Conclusions: Abnormal preoperative laboratory values including hypercalcemia, anemia, and elevated ESR are independently associated with increased risk of cancer-specific death from clinically confined clear cell RCC. Consideration of these variables in future models may improve prognostic accuracy. We believe these factors should be routinely assessed and included in prospective studies of outcome in RCC patients. [Copyright &y& Elsevier]

Prostate cancer is a leading cause of mortality and morbidity worldwide. Despite years of study and effort, certain key questions remain unanswered, Including how prostate cancer is best detected and diagnosed, how it is best treated, and how best to minimize the complications of treatment. The aim of this article is to briefly address these topics to shed light on the current best practices in prostate cancer screening, diagnosis, and surgical treatment of localized disease. We examine current trends in prostate cancer epidemiology and screening, Including genetic and dietary risk factors and the newer prostate-specific antigen-derived screening modalities. Methods of diagnosis, including an overview of prostate biopsy technique and indications, and a brief review of relevant pathologic findings are provided. An in-depth analysis of traditional prostate cancer surgical management highlights the relevant advantages and disadvantages of radical retro-pubic and perineal prostatectomy. Complications of surgery, prognostic factors, and the many risk prediction models currently available are discussed. In all, this article aims to give the reader a broad overview of the basic elements of prostate cancer diagnosis and surgical treatment in the modem era. [ABSTRACT FROM AUTHOR]

Renal cell carcinoma (RCC) often presents in its metastatic form, or progresses after curative treatment. While the management of metastatic RCC has historically been mainly surgical, contemporary approaches often incorporate systemic immunotherapy. This review examines the current indications and scope of surgical treatment of patients with metastatic RCC. Surgery is sometimes indicated for symptom palliation at either the primary or secondary sites. However, other less invasive therapies may be equally effective, and should be considered carefully. Cytoreductive surgery prior to immunotherapy appears to confer a survival advantage, but only selected patients are suitable for this treatment regimen. Primary immunotherapy followed by surgical removal of the tumour in partial responders is an alternative treatment strategy, which has not yet been evaluated as in randomized trials. As immunotherapy develops further, the precise timing and role of surgery in multimodality treatment will need to be carefully evaluated. Occasionally, the complete surgical excision of metastases, and the primary tumour, if present, is feasible and this may prolong survival. Empirically, it would seem that such patients should also be treated with adjuvant immunotherapy, as eventual relapse is frequent. Surgery with the aim of inducing spontaneous tumour regression is not justifiable, given the rarity of this phenomenon. [ABSTRACT FROM AUTHOR]

The Mayo clinic experience with renal carcinoma and venous tumour thrombus is presented in this section. The authors show that the surgical management of these patients continues to develop, and that complications and mortality are decreasing. They also show that cancer-specific survival is better with renal vein involvement only, as compared with vena caval involvement. Authors from Dallas examined whether Gleason 3+4 tumours behaved differently to 4+3, and found that that the latter pattern is more aggressive. They propose that the Gleason 4 pattern deserves further molecular study. Several authors from the USA and Austria compared the performance of complexed PSA with that of total PSA and percentage free PSA; complexed PSA provided better specificity than the other two tests and reduced the number of unnecessary biopsies in patients with a total PSA of 2.6–4.0 ng/mL. To report the surgical management, complications and outcomes over three decades by tumour thrombus level for patients with renal cell carcinoma (RCC) and renal venous extension, as surgery is the most effective treatment. We assessed 540 patients who underwent surgical resection for RCC with renal venous extension between 1970 and 2000. Early and late surgical complications, including operative mortality, were compared with tumour thrombus level using the chi-square, Fisher's exact and Wilcoxon rank-sum tests. Cancer-specific survival was estimated using the Kaplan-Meier method and compared across tumour thrombus levels using log-rank tests. There were 349 (64.6%) patients with level 0 thrombus and 191 (35.4%) with inferior vena cava thrombus, including 66 (12.2%) with level I, 77 (14.3%) with level II, 28 (5.2%) with level III, and 20 (3.7%) with level IV thrombus. Patients with a higher thrombus level had more early surgical complications (respectively for level 0 to IV, 8.6%, 15.2%, 14.1%, 17.9% and 30.0%, P < 0.001). However, there was no statistically significant difference in the incidence of late complications by thrombus level ( P = 0.445). The incidence of any early surgical complication decreased from 13.4% for patients treated in 1970–1989 to 8.1% for those treated in 1990–2000 ( P = 0.064); the respective operative mortality decreased from 3.8% to 2.0% ( P = 0.260), and in patients with inferior vena cava thrombus, from 8.1% to 3.8% ( P = 0.227). The respective duration of hospitalization decreased from a median of 8 to 7 days ( P < 0.001) but the incidence of late complications increased significantly over time ( P < 0.001.) Among patients with clear cell RCC, the respective estimated 5-year cancer-specific survival rates ( Se, number still at risk) for patients with level 0 to IV thrombus were 49.1 (3.0)% (125), 31.7 (6.4)% (14), 26.3 (6.1)% (11), 39.4 (10.7)% (7) and 37.0 (12.9)% (5), ( P = 0.028). There was a statistically significant difference in outcome for patients with level 0 vs those with level >0 thrombus ( P = 0.002), but there was no significant difference in outcome by thrombus level among patients with inferior vena cava tumour thrombus ( P = 0.868). The surgical management of RCC with renal venous extension continues to develop. The incidence of early surgical complications and operative death have decreased in recent times with the introduction of improved imaging, surgical monitoring and vascular bypass techniques. There is significantly better cancer-specific survival for patients with renal vein involvement only than those with inferior vena cava involvement. [ABSTRACT FROM AUTHOR]

Accurate identification of surgical instruments is crucial for efficient workflows and patient safety within the operating room, particularly in preventing complications such as retained surgical instruments. Artificial Intelligence (AI) models have shown the potential to automate this process. This study evaluates the accuracy of publicly available Large Language Models (LLMs)—ChatGPT-4, ChatGPT-4o, and Gemini—and a specialized commercial mobile application, Surgical-Instrument Directory (SID 2.0), in identifying surgical instruments from images. The study utilized a dataset of 92 high-resolution images of 25 surgical instruments (retractors, forceps, scissors, and trocars) photographed from multiple angles. Model performance was evaluated using accuracy, weighted precision, recall, and F1 score. ChatGPT-4o exhibited the highest accuracy (89.1%) in categorizing instruments (e.g., scissors, forceps). SID 2.0 (77.2%) and ChatGPT-4 (76.1%) achieved comparable accuracy, while Gemini (44.6%) demonstrated lower accuracy in this task. For precise subtype identification of instrument names (like "Mayo scissors" or "Kelly forceps"), all models had low accuracy, with SID 2.0 having an accuracy of 39.1%, followed by ChatGPT-4o (33.69%). Subgroup analysis revealed ChatGPT-4 and 4o recognized trocars in all instances. Similarly, Gemini identified surgical scissors in all instances. In conclusion, publicly available LLMs can reliably identify surgical instruments at the category level, with ChatGPT-4o demonstrating an overall edge. However, precise subtype identification remains a challenge for all models. These findings highlight the potential of AI-driven solutions to enhance surgical-instrument management and underscore the need for further refinements to improve accuracy and support patient safety. [ABSTRACT FROM AUTHOR]

To develop and compare various models for risk stratification in chromophobe renal cell carcinoma (chrRCC). Models have been developed to predict progression-free (PFS) and cancer-specific survival (CSS) following surgery for localized renal cell carcinoma (RCC). Notably, chromophobe RCC (chrRCC) is not included in American Urological Association (AUA) risk stratification, as nuclear grading is not recommended. We queried our institutional registry to identify patients managed surgically for unilateral, sporadic, M0, chrRCC from 1970-2012. AUA risk groups were defined using reported criteria, excluding grade, and were compared to the Mayo system incorporating nodal involvement, perinephric/renal sinus fat invasion, and sarcomatoid differentiation. PFS and CSS were estimated using the Kaplan-Meier method. Predictive ability was summarized using c-indexes from Cox proportional hazard regression models. A total of 257 patients were identified. Thirty-nine patients experienced disease progression at a median 30 months (IQR 5.0-84) and 25 died from chrRCC at a median 34 months (IQR 15-79) following surgery. PFS and CSS rates at 10 years after surgery were 84% and 90%, respectively. C-indexes for modified AUA and Mayo risk groups were similar at 0.76 and 0.75, respectively, for PFS, and 0.77 and 0.76, respectively for CSS. The modified AUA and Mayo risk stratification systems have similarly robust c-indexes for PFS and CSS in chrRCC. These models can be used to counsel patients based on pathologic features, inform clinicians on appropriate follow-up pathways, and identify patients at risk of disease progression for enrollment in adjuvant systemic therapy trials. [ABSTRACT FROM AUTHOR]

Background: Retained surgical items (RSI) are preventable events that pose a significant risk to patient safety. Current strategies for preventing RSIs rely heavily on manual instrument counting methods, which are prone to human error. This study evaluates the feasibility and performance of a deep learning-based computer vision model for automated surgical tool detection and counting. Methods: A novel dataset of 1,004 images containing 13,213 surgical tools across 11 categories was developed. The dataset was split into training, validation, and test sets at a 60:20:20 ratio. An artificial intelligence (AI) model was trained on the dataset, and the model's performance was evaluated using standard object detection metrics, including precision and recall. To simulate a real-world surgical setting, model performance was also evaluated in a dynamic surgical video of instruments being moved in real-time. Results: The model demonstrated high precision (98.5%) and recall (99.9%) in distinguishing surgical tools from the background. It also exhibited excellent performance in differentiating between various surgical tools, with precision ranging from 94.0 to 100% and recall ranging from 97.1 to 100% across 11 tool categories. The model maintained strong performance on a subset of test images containing overlapping tools (precision range: 89.6–100%, and recall range 97.2–98.2%). In a real-time surgical video analysis, the model maintained a correct surgical tool count in all non-transition frames, with a median inference speed of 40.4 frames per second (interquartile range: 4.9). Conclusion: This study demonstrates that using a deep learning-based computer vision model for automated surgical tool detection and counting is feasible. The model's high precision and real-time inference capabilities highlight its potential to serve as an AI safeguard to potentially improve patient safety and reduce manual burden on surgical staff. Further validation in clinical settings is warranted. [ABSTRACT FROM AUTHOR]

Medical researchers are increasingly utilizing advanced LLMs like ChatGPT-4 and Gemini to enhance diagnostic processes in the medical field. This research focuses on their ability to comprehend and apply complex medical classification systems for breast conditions, which can significantly aid plastic surgeons in making informed decisions for diagnosis and treatment, ultimately leading to improved patient outcomes. Fifty clinical scenarios were created to evaluate the classification accuracy of each LLM across five established breast-related classification systems. Scores from 0 to 2 were assigned to LLM responses to denote incorrect, partially correct, or completely correct classifications. Descriptive statistics were employed to compare the performances of ChatGPT-4 and Gemini. Gemini exhibited superior overall performance, achieving 98% accuracy compared to ChatGPT-4's 71%. While both models performed well in the Baker classification for capsular contracture and UTSW classification for gynecomastia, Gemini consistently outperformed ChatGPT-4 in other systems, such as the Fischer Grade Classification for gender-affirming mastectomy, Kajava Classification for ectopic breast tissue, and Regnault Classification for breast ptosis. With further development, integrating LLMs into plastic surgery practice will likely enhance diagnostic support and decision making. [ABSTRACT FROM AUTHOR]

The authors discuss the role of lymph node dissection (LND) in the management of genito-urinary malignancies like renal cell carcinoma. They explore the oncologic benefits of LND in patients with nonmetastatic RCC with considerations on increased risk for nodal metastases using a number of propensity score techniques for nonrandom treatment allocation. It suggests that aggressive lymphadenectomy is not applicable to the majority of patients with nonmetastatic RCC.

In postoperative care, patient education and follow-up are pivotal for enhancing the quality of care and satisfaction. Artificial intelligence virtual assistants (AIVA) and large language models (LLMs) like Google BARD and ChatGPT-4 offer avenues for addressing patient queries using natural language processing (NLP) techniques. However, the accuracy and appropriateness of the information vary across these platforms, necessitating a comparative study to evaluate their efficacy in this domain. We conducted a study comparing AIVA (using Google Dialogflow) with ChatGPT-4 and Google BARD, assessing the accuracy, knowledge gap, and response appropriateness. AIVA demonstrated superior performance, with significantly higher accuracy (mean: 0.9) and lower knowledge gap (mean: 0.1) compared to BARD and ChatGPT-4. Additionally, AIVA's responses received higher Likert scores for appropriateness. Our findings suggest that specialized AI tools like AIVA are more effective in delivering precise and contextually relevant information for postoperative care compared to general-purpose LLMs. While ChatGPT-4 shows promise, its performance varies, particularly in verbal interactions. This underscores the importance of tailored AI solutions in healthcare, where accuracy and clarity are paramount. Our study highlights the necessity for further research and the development of customized AI solutions to address specific medical contexts and improve patient outcomes. [ABSTRACT FROM AUTHOR]

With abundant information and interconnectedness among people, identifying knowledgeable individuals in specific domains has become crucial for organizations. Artificial intelligence (AI) algorithms have been employed to evaluate the knowledge and locate experts in specific areas, alleviating the manual burden of expert profiling and identification. However, there is a limited body of research exploring the application of AI algorithms for expert finding in the medical and biomedical fields. This study aims to conduct a scoping review of existing literature on utilizing AI algorithms for expert identification in medical domains. We systematically searched five platforms using a customized search string, and 21 studies were identified through other sources. The search spanned studies up to 2023, and study eligibility and selection adhered to the PRISMA 2020 statement. A total of 571 studies were assessed from the search. Out of these, we included six studies conducted between 2014 and 2020 that met our review criteria. Four studies used a machine learning algorithm as their model, while two utilized natural language processing. One study combined both approaches. All six studies demonstrated significant success in expert retrieval compared to baseline algorithms, as measured by various scoring metrics. AI enhances expert finding accuracy and effectiveness. However, more work is needed in intelligent medical expert retrieval. [ABSTRACT FROM AUTHOR]

The article discusses the classification and characteristics of clear cell papillary renal cell tumours (CCPRCT). The recent World Health Organization (WHO) classification changed the nomenclature of these tumours to emphasize their indolent clinical behavior. The article presents a case study of a patient with a metastatic CCPRCT and compares the primary and metastatic tumors. The authors argue that the change in nomenclature may lead to unnecessary expensive testing and suggest reverting to the original terminology. They also highlight the need for further studies to determine the clinical impact of distinguishing CCPRCT from other renal cell carcinomas. [Extracted from the article]

Approximately 70% of cases of kidney cancer are localized or locally advanced at diagnosis. Among patients who undergo surgery for these cancers, 30-35% will eventually develop potentially fatal metachronous distant metastases. Effective adjuvant treatments are urgently needed to reduce the risk of recurrence of kidney cancer and of dying of metastatic disease. To date, almost all of the tested adjuvant agents have failed to demonstrate any benefit. Only two trials of an autologous renal tumour cell vaccine and of the vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitor sunitinib have shown positive results, but these have been criticized for methodological reasons and conflicting data, respectively. The results of two additional trials of targeted agents as adjuvant therapies have not yet been published. Novel immune checkpoint inhibitors are promising approaches to adjuvant therapy in kidney cancer, and a number of trials are now underway. An important component of the management of patients with kidney cancer, particularly those who undergo radical resection for localized renal cell carcinoma, is the preservation of kidney function to reduce morbidity and mortality. The optimal management of these patients therefore requires a multidisciplinary approach involving nephrologists, oncologists, urologists and pathologists. [ABSTRACT FROM AUTHOR]

Background The Surgery in Early Metastatic Seminoma (SEMS) trial examined retroperitoneal lymph node dissection as first-line treatment for patients with isolated 1-3 cm retroperitoneal lymphadenopathy. To date, the standard of care for these patients has been either chemotherapy or radiotherapy. Herein, we evaluated the relative cost-effectiveness of these management strategies. Methods A microsimulation model assessed the cost-effectiveness of retroperitoneal lymph node dissection, chemotherapy, and radiotherapy for stage IIA seminoma. Sensitivity analyses were performed to evaluate model robustness. Retroperitoneal lymph node dissection recurrence probabilities were obtained from the SEMS trial. All other probability and utility values were obtained from published literature. Primary outcomes included costs from a commercial insurer's perspective, effectiveness (quality adjusted life-years [QALYs]), and incremental cost-effectiveness ratios using a willingness-to-pay threshold of $100 000/QALY. Results At a lifetime horizon, the mean costs per patient for retroperitoneal lymph node dissection, radiotherapy, and chemotherapy were $58 469, $98 783, and $104 096, and the mean QALYs were 40.61, 40.70, and 39.15, respectively. Retroperitoneal lymph node dissection was found to be the most cost-effective approach because of high costs and accrued disutility of chronic toxicities associated with radiotherapy (cost-effectiveness ratios = $433 845/QALY) and chemotherapy (dominated). On 1-way sensitivity analyses, retroperitoneal lymph node dissection was no longer cost-effective if the probabilities of infertility and cardiovascular toxicity after radiotherapy were less than 13% and 16%, respectively, or if the 2-year probability of progression after retroperitoneal lymph node dissection was more than 26%. Conclusions Retroperitoneal lymph node dissection was the most cost-effective treatment approach for stage IIA seminoma. These findings support clinical guideline consideration of including retroperitoneal lymph node dissection as a treatment option for well-selected patients with stage IIA seminoma. [ABSTRACT FROM AUTHOR]

Objective Surgical resection for renal cell carcinoma (RCC) with suprahepatic inferior vena cava tumor thrombus is associated with significant morbidity, yet there are currently no tools for preoperative prognostic evaluation. Our goal was to develop a preoperative multivariable model for prediction of survival and risk of major complications in patients with suprahepatic thrombi. Methods We identified patients who underwent surgery for RCC with suprahepatic tumor thrombus extension from 2000 to 2013 at 4 tertiary centers. A Cox proportional hazard model was used for analysis of overall survival (OS) and logistic regression was used for major complications within 90 days of surgery (Clavien≥3A). Nomograms were internally calibrated by bootstrap resampling method. Results A total of 49 patients with level III thrombus and 83 patients with level IV thrombus were identified. During median follow-up of 24.5 months, 80 patients (60.6%) died and 46 patients (34.8%) experienced major complication. Independent prognostic factors for OS included distant metastases at presentation (hazard ratio = 2.52, P = 0.002) and Eastern Cooperative Oncology Group (ECOG) performance status (hazard ratio = 1.84, P <0.0001). Variables associated with increased risk of major complications on univariate analysis included preoperative systemic symptoms, level IV thrombus, and elevated preoperative alkaline phosphatase and aspartate transaminase levels; however, only systemic symptoms (odds ratio = 8.45, P <0.0001) was an independent prognostic factor. Preoperative nomograms achieved a concordance index of 0.72 for OS and 0.83 for major complications. Conclusions We have developed and internally validated multivariable preoperative models for the prediction of survival and major complications in patients with RCC who have a suprahepatic inferior vena cava thrombus. If externally validated, these tools may aid in patient selection for surgical intervention. [ABSTRACT FROM AUTHOR]

The likelihood of recurrence after surgery for non-metastatic renal cell carcinoma (RCC) with venous tumor thrombus (VTT) remains considerable and previously developed predictive models remain underutilized in clinical practice. Adjuvant pembrolizumab was recently FDA approved and all RCC patients with VTT technically fall under the FDA approval guidance. However, we have previously conducted a cost-effectiveness analysis to demonstrate that the 3% survival benefit of adjuvant pembrolizumab outweighs its costs and risks when the 5-year risk of metastasis is at least 60%. As such, many patients with RCC and VTT may not benefit from adjuvant pembrolizumab treatment. The purpose of this study was to develop and internally validate an easy-to-use metastasis risk calculator after radical nephrectomy for non-metastatic RCC with VTT. We performed a single-institution retrospective analysis of all adult patients who underwent radical nephrectomy with thrombectomy for non-metastatic RCC with VTT between 2000 and 2021. Demographic, clinicopathologic, and procedural characteristics were examined for association with the primary outcome of metastasis-free survival (MFS). A 70%-30% split was used to divide the cohort into a development/training and validation cohort, respectively. A least absolute shrinkage and selection operation (LASSO) Cox regression model was used to select variable combinations that best correlated with RCC metastasis. These variables were used to develop an MFS nomogram for which the area under the curve (AUC) was measured at 5 years. Decision curve analysis was performed to compare the net benefit of a nomogram-based strategy vs a treat-all strategy. Of the 532 M0 patients, 278 (52.3%), 66 (12.4%), 116 (21.8%), 35 (6.6%), and 37 (7.0%) had a level 0, I, II, III, and IV thrombus, respectively. Baseline characteristics are found in Table 1. The 5-year MFS for VTT level 0, I, II, III, IV was 51.2%, 34.7%, 28.5%, and 33.7%, respectively (p<0.01). Using LASSO feature selection, an MFS nomogram (Figure 1A) was built using four pathologic variables: thrombus level, necrosis, sarcomatoid, and positive nodes. The nomogram separated patients into low (36% of cohort), medium, and high-risk groups for metastasis (Figure 1B) with a 5-year risk of metastasis of approximately 30%, 60%, and 80%, respectively (p<0.001). The AUC at 5-years was 0.74 for both the development and validation cohorts (Figure 1C). Decision curve analysis found a significant net benefit favoring the nomogram over a treat-all strategy when adjuvant therapy treatment thresholds were over 30% metastasis risk (Figure 1D). Identifying VTT patients who are at increased risk of recurrence is important in determining post-operative follow-up and potentially who might benefit from adjuvant therapy. Our study introduces a MFS nomogram that relies on just four pathologic variables to estimate postoperative recurrence in patients after radical nephrectomy for RCC with VTT. Further validation of this MFS nomogram and understanding more about the implications for post-operative management will be important in the future. [ABSTRACT FROM AUTHOR]

Objective: To evaluate predictors of urology resident scholarly productivity, pursuit of fellowship, and an academic career using medical student application materials.Methods: We reviewed the Mayo Clinic experience with 49 urology residents who matriculated between 2000 and 2011 and graduated between 2006 and 2016. In 2005, the duration of residency was changed from 6 to 5 years. The number of peer-reviewed original publications before and during residency was obtained via Scopus. Associations of features from the medical student application with number of publications, pursuit of fellowship, and an academic career were evaluated with logistic regression.Results: Among the 49 graduates, 19 (39%) had a peer-reviewed publication before residency. The mean (standard deviation) and median (range) number of publications during residency was 9.0 (9.4) and 6 (1-41), respectively. In a multivariable analysis, the only feature significantly associated with ≥6 publications during residency was a 6 vs 5 year residency program (odds ratio 5.71; P = .018). Twenty five (51%) residents pursued a fellowship, and the only feature significantly associated with this was female gender (odds ratio 7.33, P = .018). Seventeen (35%) residents pursued an academic career, and the only feature from the medical school record that was significantly associated with an academic career was ≥1 publication before residency (odds ratio 3.65; P = .040).Conclusion: A research year during urology residency is significantly associated with scholarly productivity. While women are more likely to pursue fellowships, the only significant predictor of an academic career using medical student application materials was a publication before residency. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the peri‐operative and renal functional outcomes of patients undergoing synchronous bilateral partial nephrectomy (PN) or percutaneous cryoablation (PCA). Patients and Methods: We retrospectively reviewed our institutional nephrectomy and renal mass ablation registries to identify all patients with synchronous bilateral renal masses who underwent simultaneous bilateral PN (n = 76) or PCA (n = 13) between 1974 and 2013. Changes in estimated glomerular filtration rate (eGFR) as well as peri‐operative complications are descriptively reported for each procedure. Results: The number of treated renal masses in the 76 patients in the PN group and the 13 patients in the PCA group was 249 and 28, respectively. The median (interquartile range [IQR]) age at treatment was 62 (50, 71) years for the PN group and 67 (56, 72) for the PCA group. The median (IQR) maximum tumour sizes were 4.6 (3.4, 6.5) cm and 2.6 (2.4, 3.2) cm for the PN and PCA groups, respectively. The median (IQR) length of hospital stay was 7 (5, 8) days for the PN group and 1 (1, 10) days for the PCA group. The median (IQR) change in eGFR from baseline to discharge was −32 (−46, −15)% for the PN group and −17% (−33, −3) for the PCA group. By 3 months, median (IQR) renal function improved, with changes of −9 (−19, 0)% and −8 (−11, 15)%, respectively, compared with baseline. No patient in either group required renal replacement therapy in the peri‐operative period. Early postoperative complications (within 30 days) occurred in 16 patients (21.6%) in the PN and four patients in the PCA group. In particular, angioembolization for bleeding was required in the postoperative period in two patients (2.7%) in the PN and one patient in the PCA group. Conclusions: Our experience suggests that synchronous bilateral PN or PCA are feasible treatment options for select patients presenting with bilateral renal masses. In select cases, both approaches appear to have reasonable rates of peri‐operative complications and effects on renal function. [ABSTRACT FROM AUTHOR]

In this article, the authors present their views on a study related to racial disparity in renal cell carcinoma patient survival conducted by the National Cancer Institute of the U.S. They state that survival of the American patients with renal cell carcinoma is more than that of the African American patients. They also talk about a recent study related to outcomes, income, socioeconomic status and access to medical care.

Objective: To evaluate features from the medical student application record that predict for a high-quality urology resident because there are currently sparse data on factors that are associated with a successful urology residency.Materials and Methods: We reviewed the Mayo Clinic experience with 53 urology residents who matriculated between 2000 and 2011. Residents were independently scored 1-10 based on overall quality by the Program Director and Associate Program Director. Discrepant scoring by >2 was resolved by the former Program Director. Associations of features from the medical student application with an excellent score (defined as 8-10) were evaluated with logistic regression.Results: Discrepant scoring >2 was noted in only 3 residents (6%). Among the 53 residents, the mean overall score was 6.2 (standard deviation 3.0, range 1-10) and 20 residents (38%) had an excellent score of 8-10. Univariably, higher United States Medical Licensing Examination step II score (P = .011), election to Alpha Omega Alpha (P = .017), no negative interview comments (P = .044), lower ranked medical school (P = .015), honors in obstetrics and gynecology clerkship (P = .044), and honors in all core clinical clerkships (P = .007) were significantly associated with an excellent score. In a multivariable model, no negative interview comments (P = .018), lower ranked medical school (P = .012), and honors in all core clinical clerkships (P = .006) were independently associated with an excellent score; the c-index for this model was 0.91.Conclusion: We demonstrate features associated with an excellent urology resident, most notably an honors grade in all core clinical clerkships. [ABSTRACT FROM AUTHOR]

To contrast surgical outcomes of Horseshoe Kidney (HSK) patients with localized renal masses suspected of cancer with nonfused nonectopic kidney patients, emphasizing safe surgical practices for HSKs. The study examined solid tumors from the Mayo Clinic Nephrectomy registry between 1971 and 2021. Each HSK case was matched to three non-HSK patients based on various factors. The outcomes measured included complications within 30 days of surgery, change in estimated glomerular filtration rate, and overall, cancer-specific, and metastasis-free survival rates. Thirty of the 34 HSKs had malignant tumors compared with 90 of the 102 patients in the nonfused nonectopic referent cohort. Accessory isthmus arteries were present in 93% of HSK cases, with 43% exhibiting multiple arteries and 7% with 6 or more arteries. Estimated blood loss and surgery duration were significantly higher in HSKs (900 vs 300 mL, P =.004; 246 vs 163 minutes, P <.001, respectively). The HSK group demonstrated an overall complication rate of 26% (vs 17% in referents, P =.2) and a median change in estimated glomerular filtration rate at 3 months of − 8.5 (vs − 8.1 in referents, P =.8). At 5-year follow-up, survival rates for HSK patients were 72%, 91%, and 69% for overall, cancer-specific, and metastasis-free survival, respectively. The corresponding rates were 79%, 86%, and 77%, respectively, for matched referent patients (P >.05). HSK tumor management is technically challenging with higher blood loss; however, the data demonstrate comparable outcomes for patients with HSK tumors, including complications and survival, to those without HSKs in experienced centers. [ABSTRACT FROM AUTHOR]

* Context.--Epithelioid angiomyolipomas (eAMLs) are rare tumors of the kidney that occur in patients with tuberous sclerosis complex or in a sporadic setting; a subset of these tumors exhibit metastatic behavior. Objective.--To analyze molecular profiling data to identify pathogenic alterations in rare cases of metastatic eAML, and to identify immunohistochemistry (IHC)-based surrogate markers. Design.--Molecular profiling data from the American Association for Cancer Research GENIE registry was accessed for 23 patients with angiomyolipomas, and 9 of 16 patients with eAMLs in our institutional registry were evaluated with next-generation sequencing. IHC was performed to screen for alterations of P53, RB, and ATRX for all 16 institutional cases. Results.--Combined alterations of 5 tumor-suppressor genes (TP53, ATRX, RB1, APC, and NF1) were identified using next-generation sequencing in 7 of 8 (88%) patients with metastatic disease compared to a single patient with nonmetastatic disease (RB1 variant of uncertain significance; 1 of 24, 4%). No cases with abnormal IHC results were identified in 11 patients with nonmetastatic disease compared to 3 of 5 patients with metastatic disease. Conclusions.--Our results show that the majority of metastatic eAMLs have mutations of 5 tumor-suppressor genes (TP53, ATRX, RB1, APC, and NF1), while these are rare in patients with nonmetastatic disease. Furthermore, IHC for P53, RB, and ATRX may serve as a screen for a subset of these alterations in resource-limited settings. These findings, if validated in larger data sets, have the potential to predict metastatic behavior in eAMLs. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about nephron-sparing surgery and renal cell carcinoma.

For patients with kidney cancer, contemporary radical nephrectomy (RN) pathways have moved towards optimized workflows, refined care team structures, and utilization of minimally invasive techniques. In addition, the pressure to avoid inpatient stays during the COVID-19 pandemic has also accelerated care pathways for earlier discharge. Meanwhile, the Centers for Medicare and Medicaid Services has maintained RN on the inpatient only procedure list preventing its widespread adoption in ambulatory surgical centers. In this context, little is known regarding the evolution of discharge patterns of RN. Herein, we aimed to characterize national trends in next day discharge (NDD) after RN, identify its patient and hospital predictors, and its implications for total hospital charges. Years 2016-2020 of the National Inpatient Survey (NIS) were queried to identify RN for kidney cancer. The primary outcome was NDD, defined as a length of stay (LOS) of 1 day or less. Survey weighted univariable and multivariable logistic regressions were performed to identify patient and hospital level factors associated with NDD. The association of NDD with total hospital charges was tested using univariable and multivariable generalized linear models using a gamma distribution. STATA and R Studio were used for data abstraction and analysis, respectively. Of 224,750 RNs, 34,640 (15.4%) of patients had NDD. The proportion of NDD significantly increased from 2016 to 2020 (overall 10.2% vs 24.3%, p<0.0001), though this remained significant only for MIS, not open, RN (Figure 1). Several variables were associated with NDD (Table 1). Hospital factors associated with NDD include a smaller number of beds (OR 1.54, p<0.001) and highest RN volume quartile (OR 1.78 for highest vs lowest quartile, p<0.001). In addition, a minimally invasive approach (OR 3.58, p<0.001) was associated with NDD. NDD was associated with lower total hospital charges compared to non-NDD: $50,798 vs $68,058, p<0.0001. On multivariable generalized linear models, NDD remained associated with lower total hospital charges (OR 0.64, p<0.001). The incidence of NDD after RN has considerably more than doubled from 2016 to 2020, and NDD was associated with lower total hospital charges. NDD was more common after minimally invasive RN in high volume centers with a smaller number of total hospital beds, indicating that both minimally invasive care pathways and hospital bed turnover pressure may be driving the trend of increased NDD. Further study is warranted to ensure that patient satisfaction and readmission rates are not compromised by NDD. We also anticipate increased numbers of minimally invasive RNs will be performed with same day discharge in the future, opening the door for RN removal from the inpatient only list. [ABSTRACT FROM AUTHOR]

• Deferred cytoreductive nephrectomy represents an appropriate management option. • Deferred cytoreductive nephrectomy demonstrates improved overall survival. • Deferred and upfront cytoreductive nephrectomy carry similar morbidity burden. Deferred cytoreductive nephrectomy (dCN) after upfront systemic therapy has been utilized in the management of select patients with metastatic renal cell carcinoma (mRCC). Herein, we sought to review the current evidence and define oncologic and perioperative outcomes associated with deferred surgical management of newly diagnosed mRCC. Our objective was to critically evaluate the role of dCN in the targeted and immunotherapy eras, comparing oncologic and perioperative outcomes between dCN and upfront CN. Medline, OVID, and Scopus databases were searched for studies evaluating patients undergoing dCN following systemic therapy (ST). PRISMA guidelines were referenced and followed. Outcomes of interest included overall survival (OS), progression free survival (PFS), percent of patients proceeding to dCN, reduction in primary tumor size, complication rates, and perioperative mortality. Random effects meta-analysis was performed comparing overall survival between dCN vs. ST alone and dCN vs. upfront CN. Nineteen studies were included to assess the primary outcomes. The percent of patients proceeding to planned dCN after planned pre-surgical ST ranged from 60.5% to 84%. The most common reason for not undergoing dCN was disease progression on upfront ST. Of patients undergoing dCN, 76% to 96% were able to resume ST postoperatively. OS and PFS ranged from 12.4 to 46 months and 4.5 to 11 months, respectively. Pooled results demonstrated significantly improved OS favoring dCN over upfront CN (hazard ratio, HR = 0.56; 95% CI 0.45–0.69) and ST alone (HR = 0.45; 95% CI 0.38–0.53). Deferred CN represents a potential treatment option in appropriately selected patients with mRCC with a favorable response to upfront systemic therapy. Future randomized trials will be needed to clarify how much this is due to the surgery vs. patient selection. [ABSTRACT FROM AUTHOR]

The routine clinical implementation of molecular methods other than fluorescence in situ hybridization in the evaluation of renal neoplasia is currently limited, as the current standard of care primarily involves a combination of morphologic and immunophenotypic analysis of such tumors. Amongst various molecular techniques, global copy number profiling using single nucleotide polymorphism-based microarrays, colloquially referred to as SNP-arrays, is being increasingly utilized to profile renal tumors, as several subtypes have characteristic recurrent patterns of copy number alterations. Recurrent copy number alterations in common tumor types include loss of chromosome 3p in clear cell renal cell carcinoma (RCC), gain of chromosomes 7 and 17 in papillary RCC and multiple losses in chromosomes 1, 2, 6, 10, 13, 17, and 21 in chromophobe RCC. Such assays are being increasingly utilized in the clinical setting. Herein, we discuss some common clinical applications of such testing that includes high yield diagnostic and prognostic applications. Diagnostic utility includes evaluation of tumor types that are primarily defined by underlying copy number alterations, establishing the underlying subtype in high grade dedifferentiated (unclassified) renal tumors, as well as assessment of loss of heterozygosity, which is an important component in the workup for germline alterations in tumor suppressor genes. Universal adoption of these techniques across clinical laboratories will likely be significantly affected by variables such as cost, reimbursement, and turnaround time. [ABSTRACT FROM AUTHOR]

Objective: To compare renal functional outcomes, as determined by percent decline in estimated glomerular filtration rate (eGFR) and CKD stage progression following radical (RN) and partial nephrectomy (PN) stratified by preoperative CKD stage.Materials and Methods: We retrospectively evaluated adults treated with RN or PN between 1980 and 2018 for unilateral, sporadic, solid renal masses. Multivariable linear models for percent change in eGFR (n = 3046) and competing-risk Cox proportional hazards models for increase in CKD staging (n = 5805) were used to determine if there was a significant interaction between type of surgery (RN vs PN) and preoperative CKD stage.Results: Percent change in eGFR at 1 year was significantly worse for RN (n = 1724; 57%) compared with PN (n = 1322; 43%) for all preoperative CKD stages. RN (n = 3227; 56%) was more likely to result in CKD stage progression compared with PN (n = 2578; 44%) for preoperative CKD stages I-IIIb (P <.001) but not for CKD stage IV (P = .8).Conclusion: RN was more likely to result in decline in eGFR and CKD stage progression compared to PN for patients with preoperative CKD stage IIIb or less. Additionally, RN was associated with a significantly greater decline in eGFR at 1 year relative to PN in the CKD stage IV subset. Our data support performing PN for renal preservation when feasible. [ABSTRACT FROM AUTHOR]

Objective To evaluate outcomes of the first 18 patients treated with robot-assisted retroperitoneal lymph node dissection ( RA-RPLND) for non-seminomatous germ cell tumours ( NSGCT) and paratesticular rhabdomyosarcoma ( RMS) at our institution. Patients and Methods Between March 2008 and May 2013, 17 patients underwent RA-RPLND for NSGCT and one for paratesticular RMS. Data were collected retrospectively on patient demographics, preoperative tumour characteristics, and perioperative outcomes including open conversion rate, lymph node ( LN) yield, rate of positive LNs, operative time, estimated blood loss ( EBL), and length of stay ( LOS). Perioperative outcomes were compared between patients receiving primary RA-RPLND vs post-chemotherapy RA-RPLND. Medium-term outcomes of tumour recurrence rate and maintenance of antegrade ejaculation were recorded. Results RA-RPLND was completed robotically in 15 of 18 (83%) patients. LNs were positive in eight of 18 patients (44%). The mean LN yield was 22 LNs. For cases completed robotically, the mean operative time was 329 min, EBL was 103 mL, and LOS was 2.4 days. At a mean (range) follow-up of 22 (1-58) months, there were no retroperitoneal recurrences and two of 17 (12%) patients with NSGCT had pulmonary recurrences. Antegrade ejaculation was maintained in 91% of patients with a nerve-sparing approach. Patients receiving primary RA-RPLND had shorter operative times compared with those post-chemotherapy (311 vs 369 min, P = 0.03). There was no significant difference in LN yield (22 vs 18 LNs, P = 0.34), EBL (100 vs 313 mL, P = 0.13), or LOS (2.75 vs 2.2 days, P = 0.36). Conclusion This initial selected case series of RA-RPLND shows that the procedure is safe, reproducible, and feasible for stage I- IIB NSGCT and RMS in the hands of experienced robotic surgeons. Larger studies are needed to confirm the diagnostic and therapeutic utility of this technique. [ABSTRACT FROM AUTHOR]

Objective To evaluate the association of perioperative blood transfusion ( PBT) with survival after nephrectomy., Patients and Methods We identified 2318 patients who underwent partial or radical nephrectomy at Mayo Clinic between 1990 and 2006., PBT was defined as transfusion of allogenic red blood cells during surgery or postoperative hospitalisation., Survival was estimated using the Kaplan- Meier method and compared with the log-rank test. Cox proportional hazards regression models were used to evaluate the association of PBT with outcome., Results In all, 498 patients (21%) received a PBT. The median (interquartile range) number of units transfused was 3 (2, 5)., Patients receiving a PBT were significantly older at surgery ( P < 0.001), more likely to be female ( P < 0.001), with more frequent symptomatic presentation ( P < 0.001), worse Eastern Cooperative Oncology Group performance status ( P < 0.001), and more frequent adverse pathological features, such as high nuclear grade ( P < 0.001), locally-advanced tumour stage ( P < 0.001) and lymph node invasion ( P < 0.001)., The median follow-up was 9.1 years. Receipt of a PBT was associated with adverse 5-year cancer-specific (68% vs 92%; P < 0.001) and overall (56% vs 82%; P < 0.001) survival., On multivariate analyses, PBT remained associated with higher risk of death from any cause (hazard ratio [ HR] 1.23; P = 0.02)., Among patients who received a PBT, an increasing number of units transfused was independently associated with increased all-cause mortality ( HR 1.08; P = 0.001)., Conclusion PBT is associated with a significantly increased risk of mortality after nephrectomy. While external validation is needed, continued efforts to minimise the use of blood products in these patients are warranted. [ABSTRACT FROM AUTHOR]

Ipsilateral local recurrence (LR) after partial nephrectomy (PN) for renal cell carcinoma (RCC) may result from a metachronous tumor or PN bed recurrence. To date, literature has predominantly reported ipsilateral LRs collectively, although the pathophysiology and prognostic implications of these event may be distinct. We sought to assess variables associated with LR and evaluated associations of LR with metastasis and death from RCC. We identified adults undergoing PN for unilateral, sporadic, localized RCC from 2000 to 2019 using a prospectively maintained, single institution registry. LR was defined as new, enhancing tumor within/near the PN bed on MRI/CT. Cox proportional hazards models were used to create a preoperative risk score for LR and to examine the association of LR with metastasis and CSS following PN among patients with clear cell RCC. In a cohort of 2,164 PNs, 106 true LRs were identified, for a 10-year incidence of 6.2%. A preoperative risk score for LR based on age, symptoms, solitary kidney, complex tumor necessitating open partial nephrectomy, and cT stage was created (c-index = 0.73). Postoperatively, positive margins, pT stage, and clear cell subtype were associated with LR. Notably, 21% (23/106) of patients with LR presented with synchronous metastases. Following LR, 5-year metastasis-free and cancer-specific survival were 64% and 71%, respectively. LR remained associated with metastasis (HR 6.25; P < 0.001) and death from RCC (HR 1.93; P = 0.03) on multivariable analysis. We developed a preoperative risk score to identify patients at risk for LR following PN. LR was an independent risk factor for metastasis and death from RCC. Further study is warranted to determine whether treatment of LR improves oncologic outcomes. [ABSTRACT FROM AUTHOR]

Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Growth of small renal masses has been shown to be variable, with mean growth rates ranging from 1 to 5 mm/year in several series. Small numbers of oncocytomas in these series show similar but variable growth rates of 0.5-5.2 cm/year with no statistically significant difference compared with RCCs. This study gathered growth rate data from the largest pool ( n= 33) of pathologically proven oncocytomas to date, using current imaging techniques. Primarily, it confirms the variable growth of renal oncocytomas over an extended period of time with mean ( sd) growth of 2.9 (2.6) mm/year over a mean of 36 months. Observed oncocytoma growth was equivalent to that previously established for RCCs, and small renal masses generally, under surveillance. Secondarily, we found considerable similarity in tumour measurements between observers, suggesting that even low growth rates may be reproducibly documented. OBJECTIVE To describe the growth rates of oncocytomas before treatment with surgical resection or percutaneous ablation., PATIENTS AND METHODS This single-institution retrospective study included 33 consecutive, pathologically proven renal oncocytomas with serial contrast-enhanced computed tomography scans spanning at least 1 year before intervention, from 2000 to 2009., Tumours were measured by two radiologists, and growth rates and interobserver variability were calculated., The mean (range) pre-procedural imaging surveillance period was 36 (12-124) months (median 33 months)., RESULTS The mean ( sd) oncocytoma size was 17 (11) mm (range 4-47 mm, median 15 mm) in maximum transverse diameter on initial imaging and grew to a mean ( sd) of 26 (5) mm (range 10-83 mm, median 23 mm) by the time of treatment., Overall, the mean ( sd) and median growth rates were 2.9 (2.6) mm/year and 2.7 mm/year, respectively (range −1.2-10.9 mm/year). After weighting by the se of each tumour's growth rate, the mean ( sd) change was 2.1 (1.2) mm/year., The mean (range) interobserver variability for each tumour measurement was 1 (0-7) mm with an intraclass correlation coefficient of 0.99., CONCLUSIONS Renal oncocytomas grow at a rate similar to reported growth rates of renal cell carcinoma., As the observation of growth does not distinguish between benign and malignant renal tumours, growth of small renal masses under active surveillance should be carefully considered before a switch is made to intervention. [ABSTRACT FROM AUTHOR]

Objective: To characterize the incidence and clinicopathologic factors associated with late recurrence after surgical resection for renal cell carcinoma (RCC) because the recurrence patterns >5 years after nephrectomy have been poorly described. Methods: We identified 1454 patients treated with nephrectomy for localized RCC from 1970 to 2000 who had remained free of disease for 5 years. Subsequent tumor recurrence was classified as renal recurrence and distant metastasis. The incidence of recurrence >5 years from surgery was estimated using the Kaplan-Meier method. The associations of clinicopathologic variables with late recurrence were analyzed using Cox proportional hazard regression models. Results: With a median postoperative follow-up of 13.9 years (range 5.1-38.9), 63 patients (4.3%) experienced late renal recurrence at a median of 9.3 years (range 5.1-25.3), and 172 patients (11.8%) developed late distant metastases at a median of 9.6 years (range 5.1-26.6) after surgery. The estimated recurrence-free survival rate at 10 and 15 years was 97.3% and 95.2% for renal recurrence, and 93.1% and 85.9% for distant metastases, respectively. On multivariate analysis, increased tumor size (hazard ratio [HR] 1.12; P < .001) was associated with late renal tumor recurrence, and increased tumor size (HR 1.07; P = .018), clear cell or collecting duct histologic features (HR 3.76; P < .001), and tumor Stage pT1b (HR 2.8; P < .001), pT2a (HR 4.5; P < .001), pT2b (HR 3.4; P = .007), and pT3-pT4 (HR 5.1; P < .001) were associated with distant metastasis. Conclusion: After an initial 5-year postoperative disease-free interval, approximately 5% and 15% of patients will develop renal recurrence and distant metastases, respectively, during the next decade. Therefore, long-term surveillance remains necessary after nephrectomy. [ABSTRACT FROM AUTHOR]

OBJECTIVE • To review experience with nephrectomy/thrombectomy for a renal cell carcimoma (RCC) with a level IV tumour thrombus and to evaluate the benefit of deep hypothermic circulatory arrest (DHCA) with cardiopulmonary bypass (CPBP). PATIENTS AND METHODS • A multi-institutional retrospective database was created to assess the outcomes of surgery for RCC and associated level IV tumour thrombus from 1983 to 2007. Patients were identified based on radiographic records/operative findings. • Only cases using CPBP were analysed. Clinicopathological and operative characteristics including use of DHCA were recorded. • Overall survival (OS) for all patients and by use of DHCA was assessed. Comparisons of clinical and operative characteristics by use of DHCA were performed. • A Cox regression model determined predictors of perioperative/in-hospital mortality. RESULTS • In all, 63 patients underwent resection with CPBP; overall perioperative mortality was 22.2%. • There were no significant differences in clinicopathological characteristics, operative duration, estimated blood loss, transfusions, and hospital stay by use of DHCA. • Perioperative mortality rate was lower in patients undergoing DHCA (8.3% vs 37.5%, P = 0.006). • The median OS was longer for the patients undergoing DHCA (15.8 vs 7.7 months); however, this failed to reach statistical significance ( P = 0.357). • On multivariate analysis, age of > 60 years (hazard ratio [HR] 6.7, 95% confidence interval [CI] 1.5-31.1, P = 0.015) and the use of DHCA (HR 0.13, 95% CI 0.036-0.51, P = 0.003) were independent predictors of perioperative mortality. CONCLUSIONS • Radical nephrectomy and level IV tumour thrombectomy is associated with significant mortality. • The use of DHCA does not appear to adversely affect operative characteristics and may limit perioperative mortality. • Further prospective studies should be performed to confirm the benefit of DHCA. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether iatrogenic immunosuppression used after transplantation infers a poor prognosis of renal cell carcinoma (RCC) as natural negative immune regulators have been associated with decreased cancer-specific survival from RCC. Methods: All patients with a solid organ transplant who underwent radical nephrectomy or nephron-sparing surgery for nonhereditary sporadic RCC from 1970 to 2003 were identified and retrospectively reviewed. Results: We identified 17 patients with surgically treated rcc who also underwent a solid organ transplant: 11 with transplant before RCC and 6 with transplant after RCC. Type of transplant included 9 kidney, 3 heart, 3 liver, 1 kidney and liver, and 1 kidney and pancreas. Tumor pathology included 10 clear-cell RCC and 7 papillary RCC. At the last follow-up 6 patients died at a mean of 5.9 years after nephrectomy. Among the 11 patients still alive, mean follow-up was 7.6 years. Only 1 patient died of RCC. This patient had metastatic clear-cell RCC that was completely resected 8 years before renal transplant. He had a recurrence 2 years post transplant and died 3 years after recurrence. No other patients experienced local or distant disease recurrence. Immunosuppression was decreased in only 2 patients; one secondary to RCC metastases and another for recurrent skin cancer. Conclusions: Surgical resection of RCC in transplant patients is associated with a low rate of progression, despite optimal immunosuppression. We recommend surgical resection of low-risk, organ-confined RCC without reduction in immunosuppression in patients with solid organ transplants. [Copyright &y& Elsevier]

OBJECTIVE To examine the association between the duration of anaesthesia and non-urological complication (NUC) rates after surgery, as the increasing complexity of minimally invasive and laparoscopic procedures in urology has resulted in longer surgery and anaesthesia, and information on the effect of this on NUC rates is limited. PATIENTS AND METHODS We identified 2196 patients who had open radical nephrectomy or nephron-sparing surgery at our institution between 1989 and 2002. Patients were subdivided into groups I, II, and III according to the duration of general anaesthesia (<4, 4–6 and ≥6 h, respectively). NUCs after surgery, and mortality during and after surgery, were evaluated. RESULTS There were 1340, 723, and 133 patients in groups I, II and III, respectively. The incidences of any NUC were 3.1%, 5.8% and 13.5%, respectively. The odds ratios for the likelihood of a NUC were 1.91 ( P = 0.004) and 4.84 ( P < 0.001) for groups II and III, respectively. These differences remained significant even after adjusting for patient and tumour characteristics. Perioperative mortality was highest in group III, at 2.3%, vs 0.4% in groups I and II. CONCLUSIONS Longer anaesthesia is associated with an increase in the incidence of perioperative complications and mortality, especially when the duration of anaesthesia is >6 h. This increase appears to be independent of patient’s preoperative health status, tumour extent and blood loss. [ABSTRACT FROM AUTHOR]

OBJECTIVE To evaluate patients with multiple ipsilateral renal tumours and to determine outcomes of nephron-sparing surgery (NSS) and radical nephrectomy (RN), as the treatment of unrecognized sporadic multifocal tumours at NSS presents a surgical dilemma. PATIENTS AND METHODS In all, 104 patients had surgery between 1970 and 2003 for sporadic multiple ipsilateral renal tumours, at least one of which was renal cell carcinoma (RCC); 114 were treated with RN and 26 with NSS. Cancer-specific survival (CSS) was estimated using the Kaplan-Meier method. RESULTS More patients treated with NSS had a solitary kidney than those undergoing RN (six, 23%, vs none, P < 0.001). Seventeen of the 114 having RN died from RCC at a median (range) of 3.4 (0.25–10.3) years after RN. The estimated 5-year CSS was 90.5%. There was metachronous recurrence in nine patients at a median of 5.6 (1–14 ) years after. Two of the 26 patients having NSS died from RCC at 1 and 6 years after NSS; the 5-year CSS was 95.8%. There was local or metachronous recurrence in three patients at 7 months to 6 years after surgery; all three were alive at the last follow-up. In 26 (23%) of the 114 patients treated with RN, only one tumour was RCC. CONCLUSION Patients undergoing either RN or NSS for multiple ipsilateral renal tumours have a favourable CSS. A planned NSS is safe if small satellite lesions are resectable. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess the risk of local recurrence, systemic progression, and death from cancer among patients who experience biochemical relapse after radical retropubic prostatectomy and to stratify those patients by prostate-specific antigen (PSA) doubling time (DT). PATIENTS AND METHODS: We identified patients who experienced biochemical recurrence (defined as a PSA level ≥0.4 ng/mL) after radical prostatectomy from January 1, 1990, to December 31, 1999, for prostate adenocarcinoma. The PSA-DT was calculated by log linear regression using all PSA values within 2 years of biochemical recurrence. Local recurrence- and systemic progression-free survival and cancer-specific survival were estimated using the Kaplan-Meier method and analyzed by the log-rank test and Cox models. RESULTS: Biochemical recurrence was noted in 1521 (27%) of 5533 men during the follow-up period. Of the 1064 patients with a calculable PSA-DT, 322 (30%) had a PSA-DT of less than 1 year, 357 (34%) had a PSA-DT of 1 to 9.9 years, and 385 (36%) had a PSA-DT of 10 years or more. Patients with a PSA-DT of 10 years or more were less likely to have a higher preoperative PSA level, Gleason score, advanced pathologic stage, and seminal vesicle invasion. Patients with a PSA-DT of 10 years or more were at low risk of local recurrence (hazard ratio [HR], 0.09; 95% confidence interval [CI], 0.06–0.14; compared with patients with a PSA-DT of <1 year), systemic progression (HR, 0.05; 95% CI, 0.02–0.13), or death from cancer (HR, 0.15; 95% CI, 0.05–0.43). CONCLUSIONS: Prostate-specific antigen DT is an independent predictor of clinical disease recurrence and mortality after surgical biochemical failure. Risk stratification into high-, intermediate-, and low-risk categories based on the PSA-DT provides helpful clinical information and assists in the development of salvage therapy trials. [ABSTRACT FROM AUTHOR]

To describe the surgical management of patients with renal cell carcinoma (RCC) in a solitary kidney (managed preferentially by nephron-sparing surgery, NSS, to avoid dialysis) and extending into the renal vein or inferior vena cava (T3b). We identified 13 patients treated surgically between 1977 and 2002 for stage T3b RCC in a solitary kidney; their charts were reviewed to ascertain details of management, pathology and outcomes. NSS was successful in seven patients (four in situ and three extracorporeally). Five patients had radical nephrectomy (RN), four after failed NSS. The mean ( sem) operative duration was longer for NSS, at 5.8 (0.7) h, than RN, at 3.3 (0.6) h. There was one death during surgery before nephrectomy, and eight other complications in six patients. At a median (range) follow-up of 24 (0–204) months, eight patients had died, four from RCC (all having had NSS) at a median interval of 9.5 (7–16) months. Of the five patients alive at a median follow-up of 25 months, four had no identifiable disease, whilst one had systemic recurrence. NSS combined with venous tumour thrombectomy for treating T3b RCC involving a solitary kidney is feasible, albeit complicated. There was oncological success in a third of the patients. The treatment of these patients needs to be individualized, as alternatives to NSS (RN or observation) have obvious disadvantages. [ABSTRACT FROM AUTHOR]

Personalized treatment for clinical T1 renal cortical masses (RCMs) should take into account competing risks related to tumor and patient characteristics. To develop treatment-specific prediction models for cancer-specific mortality (CSM), other-cause mortality (OCM), and 90-d Clavien grade ≥3 complications across radical nephrectomy (RN), partial nephrectomy (PN), thermal ablation (TA), and active surveillance (AS). Pretreatment clinical and radiological features were collected for consecutive adult patients treated with initial RN, PN, TA, or AS for RCMs at four high-volume referral centers (2000–2019). Prediction models used competing-risks regression for CSM and OCM and logistic regression for 90-d Clavien grade ≥3 complications. Performance was assessed using bootstrap validation. The cohort comprised 5300 patients treated with RN (n = 1277), PN (n = 2967), TA (n = 476), or AS (n = 580). Over median follow-up of 5.2 yr (interquartile range 2.5–8.7), there were 117 CSM, 607 OCM, and 198 complication events. The C index for the predictive models was 0.80 for CSM, 0.77 for OCM, and 0.64 for complications. Predictions from the fitted models are provided in an online calculator (https://small-renal-mass-risk-calculator.fredhutch.org). To illustrate, a hypothetical 74-yr-old male with a 4.5-cm RCM, body mass index of 32 kg/m2, estimated glomerular filtration rate of 50 ml/min, Eastern Cooperative Oncology Group performance status of 3, and Charlson comorbidity index of 3 has predicted 5-yr CSM of 2.9–5.6% across treatments, but 5-yr OCM of 29% and risk of 90-d Clavien grade 3–5 complications of 1.9% for RN, 5.8% for PN, and 3.6% for TA. Limitations include selection bias, heterogeneity in practice across treatment sites and the study time period, and lack of control for surgeon/hospital volume. We present a risk calculator incorporating pretreatment features to estimate treatment-specific competing risks of mortality and complications for use during shared decision-making and personalized treatment selection for RCMs. We present a risk calculator that generates personalized estimates of the risks of death from cancer or other causes and of complications for surgical, ablation, and surveillance treatment options for patients with stage 1 kidney tumors. [ABSTRACT FROM AUTHOR]

Some patients with polycystic kidney disease present with renal neoplasia. In rare instances, tumors occur secondary to contiguous deletions of the PKD1 and TSC2 genes. Identification of PKD1/TSC2 contiguous gene deletion syndrome may improve prognostication and guide genetic counseling. To determine the incidence of renal neoplasia among patients undergoing nephrectomy for polycystic kidney disease (PKD), we queried our institutional nephrectomy registry (years 2000–2020). Approximately 4% (231 of 5757) of patients who underwent nephrectomy had PKD, and 26 of these 231 patients (11.3%) had renal neoplasia. Tumors from an additional two patients with PKD were also evaluated. Patients with PKD who had tuberous sclerosis complex (TSC)-associated renal neoplasia were screened for PKD1/TSC2 contiguous gene deletion syndrome (CGS) using single nucleotide polymorphism arrays. The median age of patients with PKD and renal neoplasia at nephrectomy was 54 yr. The median tumor size was 2.0 cm and the tumors were predominantly of low grade and stage. The tumors consisted of 23 renal cell carcinomas (RCCs), one epithelioid angiomyolipoma, and four angiomyolipomas. The median follow-up was 59.5 mo (n = 26) and only one patient with clear cell RCC developed metastases. Two patients with angiomyolipomas had PKD1/TSC2 CGS. Our results support screening of patients with PKD and TSC-associated renal neoplasia as well as TSC patients with cystic renal disease for CGS, as identification of patients with CGS can better define the manifestation and prognosis of CGS and guide counseling regarding patterns of inheritance. We identified patients with abnormal kidney cell growth (called renal neoplasia) among those undergoing removal of kidney tissue for polycystic kidney disease (PKD) and patients with a syndrome involving deletions in two genes, called PKD1/TSC2 contiguous gene deletion syndrome (CGS) at our institution. Of 231 PKD patients with removal of kidney tissue, 11.3% had renal neoplasia, and two patients with angiomyolipoma tumors had PKD1/TSC2 CGS. Detection of renal neoplasia associated with a condition called tuberous sclerosis complex in PKD may increase the identification of patients with PKD1/TSC2 CGS and guide patient counseling regarding outcomes and patterns of inheritance. [ABSTRACT FROM AUTHOR]

Objective: To report perioperative, renal functional and oncologic outcomes for patients undergoing partial or radical nephrectomy for cT2 renal masses. Methods: Retrospective review of patients who underwent partial (n = 72) or radical nephrectomy (n = 379) for cT2 renal masses from 2000 to 2016. After propensity adjustment using inverse probability weighting, the following were compared by surgery (partial or radical nephrectomy): complications, renal function measured by estimated glomerular filtration rate as continuous and as <60 mL/min/1.73 m2 at 1 and 3 years postoperatively and overall, metastases‐free survival and cancer‐specific survival in patients with renal cell carcinoma. Results: After propensity adjustment, clinical and radiographic features were well‐balanced between groups. Overall and severe complications were more common for partial compared with radical nephrectomy, although not statistically significant (19 vs 13%, P = 0.14 and 4 vs 2%, P = 0.3, respectively). Estimated glomerular filtration rate change at 1 and 3 years was more pronounced in radical compared with partial nephrectomy (median −16 vs −5 and −14 vs −2, respectively, P < 0.001). A greater proportion of radical nephrectomy patients had an estimated glomerular filtration rate <60 at 1 and 3 years (55 vs 17% and 48 vs 17%, respectively, P < 0.01). In renal cell carcinoma patients, overall, metastases‐free and cancer‐specific survival were not significantly different between groups (median survivor follow up 7.1 years, interquartile range 3.6–11.4). Conclusions: Partial nephrectomy appears to be a relatively safe and a potentially effective treatment for cT2 renal masses, conferring better renal functional preservation compared with radical nephrectomy. These data support continued use of partial nephrectomy for renal masses >7 cm in appropriately selected patients. [ABSTRACT FROM AUTHOR]

Sarcomatoid renal cell carcinoma (sRCC) is a rare histological subtype of RCC that carries a poor prognosis. Understanding sRCC tumor biology and optimization of treatment has been limited by its rarity and subsequent paucity of data. Here we present the initial descriptive analysis of sRCC data spanning multiple decades from a multi-institutional consortium dedicated to determining the underpinnings of sRCC. A multi-institutional retrospective analysis of patients with sRCC that underwent nephrectomy was conducted. We identified 1022 patients from 4 sites (Memorial Sloan Kettering: n = 228, UCLA: n = 226, MD Anderson: n = 423, Mayo Clinic: n = 145) between 1986-2019. Survival;was calculated based on death or last known follow up.;Demographic data, clinical presentation, and survival outcomes were captured and analyzed. The cohort consisted of 708 (69.3%);males and 314 (30.7%);females. Post-surgical median follow-up was 14.6 months (IQR 5.7-40.2).;563 (80.2%) presented with systemic symptoms such as fatigue/hematuria, and 139 (19.8%) were incidentally discovered. Preoperatively, 656 (64.2%);were metastatic, while 366 (35.8%);were localized on imaging. 83 (12.6%) patients underwent;neoadjuvant chemotherapy.;Final specimen AJCC stage distribution was 9.3% (92) Stage I, 8.6% (85);Stage II, 66.5% (655) Stage III, and 15.5% (153) Stage IV. Most common histology was clear-cell 78.0% (764), followed by 5.0% (49) chromophobe, 4.2% (41) papillaryNOS, 2.3% (23) papillary-type2, and 2.0% collecting-duct (20) with 5.6% (55) unclassified. In those with clinically localized disease, recurrence occurred in 57.5% (369); 83.8% (218) had distant recurrence, with 11.2% (29) local, and 5.0% (13) regional. At last follow-up 16.0% (157) were NED, 14.6% (144) AWD, 63.7% (626) DOD, and 5.7% (56) dead of unknown causes. Median CSS was 10.9 months, and median OS was 11.2 months. sRCC typically presents as advance disease (stage III or greater) with symptoms commonly present. Most localized patients without evidence of distant metastasis;will recur despite;tumors treated with nephrectomy.;Our initial findings from a multi-institutional consortium of 1022 patients provides the largest known cohort to date detailing sRCC long-term outcomes and survival and will be used for further clinical and translational analyses. [ABSTRACT FROM AUTHOR]