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Renal mass biopsy is a useful clinical tool; nevertheless, in a majority of patients, renal mass biopsy in its current form does not alter clinical management. Its routine use in all-comers is not indicated outside of clinical protocols.

A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes.To evaluate the literature regarding pertinent surgical anatomy of the kidney and related structures, nephrometry scoring systems, and current surgical strategies for partial nephrectomy (PN).A literature review was conducted.Surgical renal anatomy fundamentally impacts PN surgery. The renal artery divides into anterior and posterior divisions, from which approximately five segmental terminal arteries originate. The renal veins are not terminal. Variations in the vascular and lymphatic channels are common; thus, concurrent lymphadenectomy is not routinely indicated during PN for cT1 renal masses in the setting of clinically negative lymph nodes. Renal-protocol contrast-enhanced computed tomography or magnetic resonance imaging is used for standard imaging. Anatomy-based nephrometry scoring systems allow standardized academic reporting of tumor characteristics and predict PN outcomes (complications, remnant function, possibly histology). Anatomy-based novel surgical approaches may reduce ischemic time during PN; these include early unclamping, segmental clamping, tumor-specific clamping (zero ischemia), and unclamped PN. Cancer cure after PN relies on complete resection, which can be achieved by thin margins. Post-PN renal function is impacted by kidney quality, remnant quantity, and ischemia type and duration.Surgical renal anatomy underpins imaging, nephrometry scoring systems, and vascular control techniques that reduce global renal ischemia and may impact post-PN function. A contemporary ideal PN excises the tumor with a thin negative margin, delicately secures the tumor bed to maximize vascularized remnant parenchyma, and minimizes global ischemia to the renal remnant with minimal complications.In this report we review renal surgical anatomy. Renal mass imaging allows detailed delineation of the anatomy and vasculature and permits nephrometry scoring, and thus precise, patient-specific surgical planning. Novel off-clamp techniques have been developed that may lead to improved outcomes.

Recent work by Gershman and colleagues adds to collective data favoring partial nephrectomy to optimize functional preservation while maintaining oncological equipoise in the management of T1 renal cancer, and should not be over-interpreted as an endorsement to preferentially perform radical nephrectomy.

Background Active surveillance (AS) has gained acceptance as a management strategy for localized renal masses. Objective To review our large single-center experience with AS. Design, setting, and participants From 2000 to 2016, we identified 457 patients with 544 lesions managed with AS from our prospectively maintained kidney cancer database. A subset analysis was performed for patients with ≥5-yr follow-up without delayed intervention (DI). Outcome measurements and statistical analysis Linear growth rates (LGRs) were estimated using linear regression for the initial LGR (iLGR) AS interval and the entire AS period. Overall survival (OS) and cumulative incidence of DI were estimated with Kaplan-Meier methods utilizing iLGR groups, adjusting for covariates. DI was evaluated for association with OS in Cox models. Results and limitations Median follow-up was 67 mo (interquartile range [IQR] 41–94 mo) for surviving patients. Cumulative incidence of DI ( n =153) after 1, 2, 3, 4, and 5 yr was 9%, 22%, 29%, 35%, and 42%, respectively. Median initial maximum tumor dimension was 2.1cm (IQR 1.5–3.1cm). Median iLGR and overall LGR were 1.9 (IQR 0–7) and 1.9 (IQR 0.3–4.2) mm/yr, respectively. Compared with the no growth group, low iLGR (hazard ratio [HR] 1.25, 95% cumulative incidence [CI] 0.82–1.91), moderate iLGR (HR 2.1, 95% CI 1.31–3.36), and high iLGR (HR 1.87, 95% CI 1.23–2.84) were associated with DI ( p =0.003). The iLGR was not associated with OS ( p =0.8). DI was not associated with OS (HR 1.34, 95% CI 0.79–2.29, p =0.3). Five-year cancer-specific mortality (CSM) was 1.2% (95% CI 0.4–2.8%). Of 99 patients on AS without DI for >5 yr, one patient metastasized. Conclusions At >5 yr, AS±DI is a successful strategy in carefully managed patients. DI often occurs in the first 2–3 yr, becoming less likely over time. Rare metastasis and low CSM rates should reassure physicians that AS is safe in the intermediate to long term. Patient summary In this report, we looked at the outcomes of patients with kidney masses who elected to enroll in active surveillance rather than immediate surgery. We found that patients who need surgery are often identified early and those who remain on active surveillance become less likely to need surgery over time. We concluded that active surveillance with or without delayed surgery is a safe practice and that, when properly managed and followed, patients are unlikely to metastasize or die from kidney cancer.

We read, with great interest, the thoughtful letter by Ficarra et al [1] regarding our recently proposed surface–intermediate–base (SIB) score for objectifying surgical technique reporting during nephron-sparing surgery (NSS) [2]. Some of the authors’ concerns address specific technical aspects of the SIB score assignment, whereas others offer opinions regarding the premise and purpose of the novel clinical research tool that we proposed. We thank Ficarra and colleagues for engaging us to clarify some of the nuances of the scoring system. Prior to our report, there were no standardised definitions for reporting NSS resection techniques in the literature. This void undermines objective and meaningful comparisons of outcomes between surgeons and institutions performing NSS. Indeed, many perioperative and postoperative outcomes are inherently influenced by the kidney surgeon’s resection strategy [3]. Consequently, standardised reporting of surgical techniques is essential. Below we address each of Ficarra and colleagues’ concerns.

In the USA and Europe, nephron-sparing surgery (NSS) has become accepted as the gold standard for renal masses of 4 cm in size [1,2]. There is general consensus in the urologic community that the acceptable increase in perioperative surgical risk inherent to partial nephrectomy (PN) is justified by the theoretical benefit of avoiding the long-term deleterious renal functional consequences associated with radical nephrectomy (RN). Concerns regarding adverse events associated with a decline in glomerular filtration rate (GFR) [3], such as cardiovascular compromise, chronic anemia, bone demineralization, and metabolic disturbances, have resulted in the intuitive and widely embraced hypothesis that NSS may result in a survival advantage when comparing PN and RN. Enthusiasm for NSS was fueled by observational studies demonstrating large differences in overall survival favoring PN [4,5], and PN rates have accordingly increased over the past decade [6]. Because of robust evidence of the oncologic efficacy of nephron-sparing excision of tumors of

A standardized reporting system of nephron-sparing surgery resection techniques is lacking. The surface-intermediate-base scoring system represents a formal reporting instrument to assist in interpretation of reported data and to facilitate comparisons in the urologic literature.

There is increasing evidence for the role of altered metabolism in the pathogenesis of renal cancer.This review characterizes the metabolic effects of genes and signaling pathways commonly implicated in renal cancer.A systematic review of the literature was performed using PubMed. The search strategy included the following terms: renal cancer, metabolism, HIF, VHL.Significant progress has been made in the understanding of the metabolic derangements present in renal cancer. These findings have been derived through translational, in vitro, and in vivo studies. To date, the most well-characterized metabolic features of renal cancer are linked to von Hippel-Lindau (VHL) loss. VHL loss and the ensuing increase in the expression of hypoxia-inducible factor affect several metabolic pathways, including glycolysis and oxidative phosphorylation. Collectively, these changes promote a glycolytic metabolic phenotype in renal cancer. In addition, other histologic subtypes of renal cancer are also notable for metabolic derangements that are directly related to the causative genes.Current knowledge of the genetics of renal cancer has led to significant understanding of the metabolism of this malignancy. Further studies of the metabolic basis of renal cell carcinoma should provide the foundation for the development of new treatment approaches and development of novel biomarkers.

Hospital rankings have become integral to the marketing strategies of many health care systems. Methodology used in compiling these lists appears highly flawed.To improve on current hospital ranking systems and to develop a more meaningful measure of a urology department's contribution to the field, we developed an academic ranking score (ARS) based on publicly available data.An active faculty list was assembled for each department. A list of all publications from each department from 2005 to 2010 was then compiled. Only publications with faculty members as first or last author were considered. The ARS was then derived by identifying the number of publications within an institution, normalized by the impact factor of the peer-reviewed journal in which the publication appeared.The 2010 U.S. NewsWorld Report (USNWR) urology list was reranked based on ARS and compared with the USNWR rank list. ARS was also calculated for several leading European urologic centers.A total of 6437 urologic publications were indexed to calculate the ARS. Two of the top three programs in the USNWR rankings dropped out of the top 10. The top 10 academically ranked programs increased or decreased an average of5 positions (range: 0-17). No correlation was seen between programs ranked in the top 10 by USNWR and our objective ARS method (Spearman ρ: -0.1; p=0.75). Because ARS only includes first- or last-author publications for faculty with clinical duties, ARS likely excludes basic science contributions and contributions from nonclinical faculty.Ranking of urology departments through quantification of each program's recent academic contribution, as captured by the ARS, differs substantially from rankings developed by USNWR. Integration of such objective measures into an overall urology program ranking system would replace current subjective opinions marred by historical biases with up-to-date merit-based assessments.

Counseling patients with enhancing renal mass currently occurs in the context of significant uncertainty regarding tumor pathology.We evaluated whether radiographic features of renal masses could predict tumor pathology and developed a comprehensive nomogram to quantitate the likelihood of malignancy and high-grade pathology based on these features.We retrospectively queried Fox Chase Cancer Center's prospectively maintained database for consecutive renal masses where a Nephrometry score was available.All patients in the cohort underwent either partial or radical nephrectomy.The individual components of Nephrometry were compared with histology and grade of resected tumors. We used multiple logistic regression to develop nomograms predicting the malignancy of tumors and likelihood of high-grade disease among malignant tumors.Nephrometry score was available for 525 of 1750 renal masses. Nephrometry score correlated with both tumor grade (p0.0001) and histology (p0.0001), such that small endophytic nonhilar tumors were more likely to represent benign pathology. Conversely, large interpolar and hilar tumors more often represented high-grade cancers. The resulting nomogram from these data offers a useful tool for the preoperative prediction of tumor histology (area under the curve [AUC]: 0.76) and grade (AUC: 0.73). The model was subjected to out-of-sample cross-validation; however, lack of external validation is a limitation of the study.The current study is the first to objectify the relationship between tumor anatomy and pathology. Using the Nephrometry score, we developed a tool to quantitate the preoperative likelihood of malignant and high-grade pathology of an enhancing renal mass.

Primary androgen deprivation therapy (PADT) is frequently used as a sole modality of treatment in men with localized prostate cancer, despite a lack of clinical trial data supporting its use.To measure the impact of treatment with PADT compared to observation on overall survival in men with organ-confined prostate cancer.The design was for an observational cohort from Surveillance, Epidemiology, and End Results (SEER) Medicare data. The cohort consisted of 16,535 men aged 65-80 yr at diagnosis with organ-confined well-differentiated or moderately differentiated prostate cancer who survived1 yr past diagnosis and did not undergo treatment with prostatectomy or radiation therapy within 6 mo of diagnosis. They were diagnosed between 1991 and 1999 and followed until death or until the end of the study period (December 31, 2002).Study subjects were selected to receive PADT alone if they received luteinizing hormone-releasing hormone agonists or bilateral orchiectomy in the first 6 mo after diagnosis, and they were selected to be observed if they did not have claims for PADT during the same interval.Overall survival.After adjusting for potential confounders (ie, tumor characteristics, comorbidities, and demographics), patients who received ADT had a worse overall survival rate than patients who were observed (hazard ratio: 1.20; 95% confidence interval: 1.13-1.27). In observational studies there may be unmeasured differences between the treated and untreated groups. The SEER database does not provide information on prostate-specific antigen levels.This large, population-based study suggests that PADT did not improve survival in men with localized prostate cancer, but it suggests that PADT may instead result in worse outcomes compared with observation. Patients and physicians should be cognizant of the potential long-term side effects of ADT in a patient population for which expectant observation is an acceptable treatment strategy.

Nephron-sparing surgery (NSS) has revolutionized kidney cancer care. Indeed, partial nephrectomy (PN) is now the reference standard treatment of the patient with a small renal mass [1]. In this issue of European Urology, Kaushik et al. add to the large volume of existing literature describing the apparent benefits of PN over radical nephrectomy (RN) [2]. Using the Mayo Clinic registry data, the authors retrospectively compared renal functional and survival outcomes in 442 patients who proved to have benign pathology following renal surgery between 1980 and 2008. Similar to a 2010 report from the Cleveland Clinic, the current manuscript benefits from longer followup (8.3 yr compared with 4.1 yr) [3]. Predictably, as in nearly all retrospective comparisons of patients preselected for RN or PN, NSS was associated with better postoperative renal function and an apparent benefit in overall survival [2]. With NSS enthusiastically incorporated into existing best practice guidelines in the absence of level 1 evidence [1], the RN vs PN debate was reignited by the controversial European Organization for Research and Treatment of Cancer (EORTC) 30904 trial reporting that RN may impart a survival advantage compared with PN in patients with a renal mass 5 cm and a normal contralateral kidney [4]. Although clearly an imperfect study because of poor accrual and crossover between treatment arms, this trial has been unduly perceived as flawed heresy and largely dismissed by the urologic community. Despite its flaws, the level 1 evidence of EORTC 30904 underscores the idea that a protective benefit of NSS is not universal across patient groups. Indeed, the decision between RN and PN pivots on nuanced calibration of risk. In fact, this risk balance hinges around the relative ease and favorable risk profile for RN compared with the potential long-term benefits of nephron preservation. In particular, in patients for whom increased perioperative risks of PN are nontrivial and for whom long-term benefits of PN are uncertain, such as the elderly or infirm, RN may in fact be the superior option. PN is traditionally associated with a higher risk of perioperative complications than RN [1,4]. In particular, the risk of complications rises with increasing tumor anatomic complexity. In fact, NSS for renal masses of moderate and high complexity can be associated with a >20% risk of complications when documented using standardized reporting protocols [5]. Arguably, the RN vs PN debate is most pertinent for elderly/frail patients with tumors of higher complexity, since these patients are more likely to harbor aggressive disease and thus are least appropriate for active surveillance [6]. In the current study, Kaushik et al. report that patients who underwent RN had worse mortality than patients who underwent PN (hazard ratio: 1.75; 95% confidence interval, 1.08–2.83) [2]. Indeed, it is this survival advantage of NSS, assumed to be due to the metabolic and cardiovascular protection afforded by excess renal parenchyma, that drives our enthusiasm for its use. Nevertheless, do these data meaningfully inform the current debate? Or do they reflect our aptitude for selecting healthier patients (ie, patients who are destined to live longer) for NSS, while recommending RN to individuals with shorter life expectancy? A metaanalysis examining the comparative effectiveness literature on PN and RN was recently published by the same group from the Mayo Clinic; the authors concluded that the quality of the available data suggesting a survival benefit is ‘‘low’’ [7]. In fact, this meta-analysis demonstrated that E U RO P E AN URO LOG Y 6 4 ( 2 0 1 3 ) 6 0 7 – 6 0 9

Approximately one quarter of those diagnosed succumb to renal cell carcinoma (RCC), establishing RCC as one of the deadliest of all urologic malignancies. Nevertheless, the biology of RCC is extremely heterogeneous. Although metastatic RCC remains highly lethal, many small renal cancers follow an indolent clinical course, and nodenegative, non-metastatic RCC is associated with >90% 10yr cancer-specific survival (CSS) [1]. Furthermore, the rise in routine cross-sectional imaging over the past two decades has coincided with a dramatic stage migration toward smaller, asymptomatic tumors. Unfortunately, despite increased incidental diagnosis and treatment of localized masses, no demonstrable impact on RCC-related mortality has been observed [1]. Although the use of active surveillance and ablative techniques has gained traction in selected elderly and comorbid patients [2], the gold standard treatment for localized renal tumors remains surgical excision [1]. As the evidence of an association between chronic kidney disease, cardiovascular disease, and death accumulates [3], the surgical treatment paradigm for small localized RCC has shifted from radical extirpation to nephron-sparing surgery (NSS) techniques with the goal of preserving long-term renal function without affecting cancer control. Nevertheless, until recently, the evidence supporting a survival benefit with NSS has been limited to retrospective analyses of institutional or population-based cohorts [4,5]. In 2011, the European Organization for Research and Treatment of Cancer (EORTC) reported results from a prospective phase 3 trial randomizing patients with solitary renal lesions 5 cm and a normal contralateral kidney to partial nephrectomy (PN) or radical nephrectomy (RN) [6]. In

Nephron-sparing surgery for a patient with an enhancing renal mass, while accepted as the preferred standard of care for amenable lesions, harbors a multitude of risks [1]. Percutaneous focal therapy, using thermal techniques such as cryotherapy or radiofrequency ablation (RFA), offers the potential to mitigate many of these risks by avoiding general anesthesia and surgical dissection. Nevertheless, the oncologic efficacy of focal therapy is generally considered inferior to surgical resection [2]. In the current issue of the Platinum Journal, the accomplished group of investigators from the Mayo Clinic present a large retrospective experience with nephron-sparing approaches to T1 renal masses and attempt to draw comparative effectiveness conclusions from these data [3]. The core findings of Thompson et al. focus on cT1a patients who underwent partial nephrectomy (PN) (n = 1057), percutaneous RFA (n = 180), and percutaneous cryoablation (n = 187) [3]. Although the study reports indistinguishable local recurrence-free survival among the three groups, important caveats make meaningful comparisons among the three treatment modalities extremely challenging. As with any retrospective comparative effectiveness outcome analyses, fundamental issues that undermine validity stem from inherent selection and information biases, as well as the inability to adequately control for unmeasurable confounding [4]. As such, inferences from these results for routine clinical practice must be made with extreme caution. A retrospective analysis of three different modalities for treatment of renal masses spanning more than a decade, as expected, inevitably has profound, and arguably insurmountable, issues of selection bias. The three treatment arms included vastly different tumors in vastly different

Background Although the effect of tumor complexity on perioperative outcome measures is well established, the impact of renal pelvic anatomy on perioperative outcomes remains poorly defined. Objective To evaluate renal pelvic anatomy as an independent predictor of urine leak in moderate- and high-complexity tumors undergoing nephron-sparing surgery. Design, setting, and participants Patients undergoing open partial nephrectomy (PN) for localized RCC were stratified into intermediate- and high-complexity groups using a nephrometry score (7–9 and 10–12, respectively). A renal pelvic score (RPS) was defined by the percentage of renal pelvis contained inside the volume of the renal parenchyma. On this basis, patients were categorized as having an intraparenchymal (>50%) or extraparenchymal ( Outcome measurements and statistical analysis Characteristics of patients with and without an intraparenchymal renal pelvic anatomy were compared. Results and limitations Inclusion criteria were met by 255 patients undergoing PN for intermediate (73.6%) and complex (26.4%) localized renal tumors (mean size: 4.6±2.9cm). Twenty-four (9.6%) renal pelves were classified as completely intraparenchymal. Following stratification by RPS, groups differed with respect to Charlson comorbidity index, body mass index, and largest tumor size, while no differences were observed between hospital length of stay, nephrometry score, estimated blood loss, operative time, and age. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (75% vs 6.5%; p =0.001), secondary intervention (37.5% vs 3.9%; p p =0.025). Conclusions Intraparenchymal renal pelvic anatomy is an uncommon anatomic variant associated with an increased rate of urine leak following PN. Elevated pressures within a small intraparenchymal renal pelvis might explain the increased risk. Preoperative imaging characteristics suggestive of increased risk for urine leak should be considered in perioperative management algorithms.

Aboumarzouk et al. performed a systematic review and meta-analysis of nonrandomized retrospective studies comparing the outcomes of robotic partial nephrectomy (RPN) and conventional laparoscopic partial nephrectomy (LPN) [1]. Although the study is significantly limited by the amount and the quality of available data, the authors offer a preliminary comparative assessment of the two techniques. The take-home message is that RPN is a feasible and safe alternative to LPN, potentially affording patients shorter ischemia times. The authors compared 717 patients who underwent RPN (n = 313) or LPN (n = 404) across seven studies [1]. Several issues must be considered when contextualizing this manuscript. Only three of the selected studies [2–4] included >33 robotic cases. Furthermore, the study with the highest number of RPN patients (n = 108) was a multisurgeon cohort (five surgeons) [2]. Thus, as the authors acknowledge, these data likely captured surgeon experience at the steepest point of the learning curve for RPN. In comparison, the LPN data reflected experiences of single surgeons, with four of seven studies comprising >50 patients. As such, any comparison of the current literature is greatly limited by the reality that RPN and LPN series report experiences at drastically different points on the respective learning curves. Nevertheless, with these limitations, the authors arguably crystallize an important message: RPN, even early in the learning curve, appears to be largely equivalent to LPN performed by seasoned surgeons. As with all meta-analysis and pooled studies, differences in surgical techniques (eg, zero ischemia, early unclamping, full-on clamp renorrhaphy) as well as in data acquisition and reporting can compromise the internal validity of results. Not all of the reviewed studies reported complica

The association between tumor complexity and postoperative complications after partial nephrectomy (PN) has not been well characterized.We evaluated whether increasing renal tumor complexity, quantitated by nephrometry score (NS), is associated with increased complication rates following PN using the Clavien-Dindo classification system (CCS).We queried our prospectively maintained kidney cancer database for patients undergoing PN from 2007 to 2010 for whom NS was available.All patients underwent PN.Tumors were categorized into low- (NS: 4-6), moderate- (NS: 7-9), and high-complexity (NS: 10-12) lesions. Complication rates within 30 d were graded (CCS: I-5), stratified as minor (CCS: I or 2) or major (CCS: 3-5), and compared between groups.A total of 390 patients (mean age: 58.0 ± 11.9 yr; 66.9% male) undergoing PN (44.6% open, 55.4% robotic) for low- (28%), moderate- (55.6%), and high-complexity (16.4%) tumors (mean tumor size: 3.74 ± 2.4 cm; median: 3.2 cm) from 2007 to 2010 were identified. Tumor size, estimated blood loss, and ischemia time all significantly differed (p0.0001) between groups; patient age, body mass index (BMI), and operative time were comparable. When stratified by CCS, minor and major complication rates for all patients were 26.7% and 11.5%, respectively. Minor complication rates were comparable (26.6 vs. 24.9 vs 32.8%; p=0.45), whereas major complication rates differed (6.4 vs. 11.1 vs. 21.9%; p=0.009) among tumor complexity groups. Controlling for age, gender, BMI, type of surgical approach, operative duration, and tumor complexity, prolonged operative time (odds ratio [OR]: 1.01; confidence interval [CI], 1.0-1.02) and high tumor complexity (OR: 5.4; CI, 1.2-24.2) were associated with the postoperative development of a major complication. Lack of external validation is a limitation of this study.Increasing tumor complexity is associated with the development of major complications after PN. This association should be validated externally and integrated into the decision-making process when counseling patients with complex renal tumors.

Context An increasing number of small renal masses (SRMs) with heterogeneous histology and clinical behaviour are being detected with modern radiologic imaging. Although surgical removal is the standard of care for small renal tumours, alternative minimally invasive and conservative treatment options are possible in selected patients with shorter life expectancy. Objective To systematically review indications, techniques, and outcomes of surgical and conservative treatments of SRMs. Evidence acquisition A literature search of English-language publications was performed using the Medline database from January 2000 to February 2011 using the terms renal mass and renal carcinoma in conjunction with the evaluated management options. The articles that provided the highest level of evidence were selected with the consensus of all the authors and reviewed. Evidence synthesis Only one randomised controlled trial comparing the results of elective nephron-sparing surgery and radical nephrectomy for low-stage renal tumours is available. Few comparative studies of different treatment options for SRMs have been published. The assessment of oncologic outcomes is therefore based mainly on observational studies. Most series of nonsurgical therapies have strong selection biases and relatively short follow-up. Treatment selection is based on the clinical and histologic characteristics of SRMs, on patient age and comorbidities, and on personal preferences and experience of the urologist. Conclusions Partial nephrectomy (PN) is the standard treatment for solitary SRMs whenever it is technically feasible. Laparoscopic PN is an alternative to open PN in experienced hands. The rationale of ablative treatments is to treat incidental cortical SRMs in patients at high surgical risk with potentially reduced morbidity. Active surveillance is considered an appropriate strategy for the elderly or for patients with significant comorbidity who have a shorter life expectancy. Percutaneous biopsies are increasingly being used to establish histology of SRMs and support treatment decisions, especially for patients who are candidates for nonsurgical treatment.