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Background and objective: Renal tumour biopsy (RTB) can help in risk stratification of renal tumours with implications for management, but its utilisation varies. Our objective was to report current practice patterns, experiences, and perceptions of RTB and research gaps regarding RTB for small renal masses (SRMs). Methods: Two web-based surveys, one for health care providers (HCPs) and one for patients, were distributed via the European Association of Urology Young Academic Urologist Renal Cancer Working Group and the European Society of Residents in Urology in January 2023. Key findings and limitations: The HCP survey received 210 responses (response rate 51%) and the patient survey 54 responses (response rate 59%). A minority of HCPs offer RTB to >50% of patients (14%), while 48% offer it in

Background: Currently, the landscape of surgical training is undergoing rapid evolution, marked by the initial implementation of standardized surgical training programs, which are further facilitated by the emergence of new technologies. However, this proliferation is uneven across various countries and hospitals. Objective: To offer a comprehensive overview of the existing surgical training programs throughout Europe, with a specific focus on the accessibility of simulation resources and standardized surgical programs. Design, setting, and participants: A dedicated survey was designed and spread in May 2022 via the European Association of Urology (EAU) mail list, to Young Urologist Office (YUO), Junior membership, European Urology Residents Education Program participants between 2014 and 2022, and other urologists under 40 yr, and via the EAU Newsletter. Intervention: A 64-item, online-based survey in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) using the platform of Survey Monkey (Portland, OR, USA) was realized. Outcome measurements and statistical analysis: The study involved an assessment of the demographic characteristics. Additionally, it explored the type of center, availability of various surgical approaches, presence of training infrastructure, participation in courses, organization of training, and participants' satisfaction with the training program. The level of satisfaction was evaluated using a Likert-5 scale. The subsequent sections delved into surgical training within the realms of open, laparoscopic, robotic, and endoscopic surgery, each explored separately. Finally, the investigation encompassed the presence of a structured training course and the availability of a duly validated final evaluation process. Results and limitations: There were 375 responders with a completion rate of 82%. Among them, 75% were identified as male, 50.6% were young urologists, 31.7% were senior residents, and 17.6% were junior residents. A significant majority of participants (69.6%) were affiliated with academic centers. Regarding the presence of dry lab training facilities, only 50.3% of respondents indicated its availability. Among these centers, 46.7% were primarily focused on laparoscopy training. The availability of virtual and wet lab training centers was even more limited, with rates of 31.5% and 16.2%, respectively. Direct patient involvement was reported in 80.5% of cases for open surgery, 58.8% for laparoscopy, 25.0% for robotics, and 78.6% for endourology. It is worth noting that in

Background: Robot-assisted kidney transplantation (RAKT) is increasingly performed at selected referral institutions worldwide. However, simulation and proficiency-based progression training frameworks for RAKT are still lacking, making acquisition of the RAKT-specific skill set a critical unmet need for future RAKT surgeons. Objective: To develop and test the RAKT Box, the first entirely 3D-printed, perfused, hyperaccuracy simulator for vascular anastomoses during RAKT. Design, setting and participants: The project was developed in a stepwise fashion by a multidisciplinary team including urologists and bioengineers via an iterative process over a 3-yr period (November 2019–November 2022) using an established methodology. The essential and time-sensitive steps of RAKT were selected by a team of RAKT experts and simulated using the RAKT Box according to the principles of the Vattituki-Medanta technique. The RAKT Box was tested in the operating theatre by an expert RAKT surgeon and independently by four trainees with heterogeneous expertise in robotic surgery and kidney transplantation. Surgical procedure: Simulation of RAKT. Measurements: Video recordings of the trainees’ performance of vascular anastomoses using the RAKT Box were evaluated blind by a senior surgeon according to the Global Evaluative Assessment of Robotic Skills (GEARS) and Assessment of Robotic Console Skills (ARCS) tools. Results and limitations: All participants successfully completed the training session, confirming the technical reliability of the RAKT Box simulator. Tangible differences were observed among the trainees in both anastomosis time and performance metrics. Key limitations of the RAKT Box include lack of simulation of the ureterovesical anastomosis and the need for a robotic platform, specific training instruments, and disposable 3D-printed vessels. Conclusions: The RAKT Box is a reliable educational tool to train novice surgeons in the key steps of RAKT and may represent the first step toward the definition of a structured surgical curriculum in RAKT. Patient summary: We describe the first entirely 3D-printed simulator that allows surgeons to test the key steps of robot-assisted kidney transplantation (RAKT) in a training environment before performing the procedure in patients. The simulator, called the RAKT Box, has been successfully tested by an expert surgeon and four trainees. The results confirm its reliability and potential as an educational tool for training of future RAKT surgeons.

Background: There is a lack of evidence on acute kidney injury (AKI) and new-onset chronic kidney disease (CKD) after surgery for localised renal masses (LRMs) in patients with two kidneys and preserved baseline renal function. Objective: To evaluate the prevalence and risk of AKI and new-onset clinically significant CKD (csCKD) in patients with a single renal mass and preserved renal function after being treated with partial (PN) or radical (RN) nephrectomy. Design, setting, and participants: We queried our prospectively maintained databases to identify patients with a preoperative estimated glomerular filtration rate (eGFR) of ≥60 ml/min/1.73 m2 and a normal contralateral kidney who underwent PN or RN for a single LRM (cT1-T2N0M0) between January 2015 and December 2021 at four high-volume academic institutions. Intervention: PN or RN. Outcome measurements and statistical analysis: The outcomes of this study were AKI at hospital discharge and the risk of new-onset csCKD, defined as eGFR

Context: The resection technique used to excise tumor during robotic partial nephrectomy (RPN) is of paramount importance in achieving optimal clinical outcomes. Objective: To provide an overview of the different resection techniques used during RPN, and a pooled analysis of comparative studies. Evidence acquisition: The systematic review was conducted according to established principles (PROSPERO: CRD42022371640) on November 7, 2022. A population (P: adult patients undergoing RPN), intervention (I: enucleation), comparator (C: enucleoresection or wedge resection), outcome (O: outcome measurements of interest), and study design (S) framework was prespecified to assess study eligibility. Studies reporting a detailed description of resection techniques and/or evaluating the impact of resection technique on outcomes of surgery were included. Evidence synthesis: Resection techniques used during RPN can be broadly classified as resection (non-anatomic) or enucleation (anatomic). A standardized definition for these is lacking. Out of 20 studies retrieved, nine compared “standard” resection versus enucleation. A pooled analysis did not reveal significant differences in terms of operative time, ischemia time, blood loss, transfusions, or positive margins. Significant differences favoring enucleation were found for clamping management (odds ratio [OR] for renal artery clamping 3.51, 95% confidence interval [CI] 1.13–10.88; p = 0.03), overall complications (OR for occurrence 0.55, 95% CI 0.34–0.87; p = 0.01) major complications (OR for occurrence 0.39, 95% CI 0.19–0.79; p = 0.009), length of stay (weighted mean difference [WMD] −0.72 d, 95% CI −0.99 to −0.45; p

Context: Owing to population ageing, a growing number of kidney transplants (KTs) in elderly population are being performed. KT is the best treatment for patients with end-stage renal disease (ESRD). However, in older patients, the decision between dialysis and KT can be difficult due to potential inferior outcomes. Few studies have been published addressing this issue, and literature outcomes are controversial. Objective: To conduct a systematic review and meta-analysis to appraise the evidence about outcomes of KT in elderly patients (>70 yr). Evidence acquisition: A systematic review and meta-analysis (PROSPERO registration: CRD42022337038) was performed. Search was conducted on PubMed and LILACS databases. Comparative and noncomparative studies addressing outcomes (overall survival [OS], graft survival [GS], complications, delayed graft function [DGF], primary nonfunction, graft loss, estimated glomerular filtrate rate, or acute rejection) of KT in people older than 70 yr were included. Evidence synthesis: Of the 10 357 yielded articles, 19 met the inclusion criteria (18 observational studies, one prospective multicentre study, and no randomised controlled trials), enrolling a total of 293 501 KT patients. Comparative studies reporting enough quantitative data for target outcomes were combined. There were significant inferior 5-yr OS (relative risk [RR], 1.66; 95% confidence interval [CI], 1.18–2.35) and 5-yr GS in the elderly group (RR, 1.37; 95% CI, 1.14–1.65) to those in the

Context: Robot-assisted partial nephrectomy (RAPN) has gained increasing popularity as primary minimally invasive surgical treatment for localized renal tumors, and it has preferably been performed with a transperitoneal approach. However, the retroperitoneal approach represents an alternative approach given potential advantages. Objective: To provide an updated analysis of the comparative outcomes of retroperitoneal RAPN (R-RAPN) versus transperitoneal RAPN (T-RAPN). Evidence acquisition: A systematic review of the literature was performed up to September 2021 using MEDLINE, EMBASE, and Web of Science databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. A sensitivity analysis was performed considering only matched-pair studies. Evidence synthesis: Seventeen studies, which were published between 2013 and 2021, were retrieved. None of them was a randomized clinical trial. Among the 6,266 patients included in the meta-analysis, 2261 (36.1%) and 4,005 (63.9%) underwent R-RAPN and T-RAPN, respectively. No significant difference was found in terms of baseline features. The T-RAPN group presented a higher rate of male patients (odds ratio [OR]: 0.86, p = 0.03) and larger tumor size (weighted mean difference [WMD]: 0.2 cm; p = 0.003). The R-RAPN group reported more frequent posterior renal masses (OR: 0.23; p

Background: While robot-assisted kidney transplantation (RAKT) from living donors has been shown to achieve favourable outcomes, there is a lack of evidence on the safety and efficacy of RAKT as compared with the gold standard open kidney transplantation (OKT) in the setting of deceased donors, who represent the source of most grafts worldwide. Objective: To compare the intraoperative, perioperative, and midterm outcomes of RAKT versus OKT from donors after brain death (DBDs). Design, setting, and participants: Data from consecutive patients undergoing RAKT or OKT from DBDs at a single academic centre between October 2017 and December 2020 were prospectively collected. Intervention: RAKT or OKT. Outcome measurements and statistical analysis: The primary outcomes were intraoperative adverse events, postoperative surgical complications, delayed graft function (DGF), and midterm functional outcomes. A multivariable logistic regression analysis assessed the independent predictors of DGF, trifecta, and suboptimal graft function (estimated glomerular filtration rate [eGFR]

Background: Some renal tumors have an imperative indication for nephron-sparing surgery (NSS), such as in cases of chronic kidney disease and bilateral complex tumors. Objective: To demonstrate the degree to which three-dimensional virtual model (3DVM) assistance can be helpful in planning the surgical strategy for high-complexity renal masses with an imperative indication for NSS. Design, setting, and participants: Three patients with high-complexity renal masses with unusual anatomy and an imperative indication for NSS were prospectively selected across 2020 and 2021 at our institution. All patients underwent contrast-enhanced computed tomography from which a 3DVM was obtained. Surgical procedure: Robot-assisted partial nephrectomy with 3DVM augmented reality guidance. Measurements: Demographics and tumor-related features were recorded. Data for intraoperative, pathological, and functional assessments were collected for all three patients. Results and limitations: Two of the three patients harbored bilateral renal tumors. The third patient presented with a renal mass in the left kidney and contralateral renal hypoplasia (right-split renal function of 25%). All of the patients demonstrated similar anatomical and tumor features on 3DVMs, with potentially independent vascularization and drainage for the lower pole. In one patient the upper pole of the kidney was spared, exiting in a functionally excluded hydrocalyx, while in the other two cases the upper pole was removed together with the lesion. The spared portion of the kidney retained vascularization, as demonstrated by intraoperative ultrasound and indocyanine green injection. The small sample size and short follow-up are the main limitations of the study. Conclusions: 3DVMs, especially for complex renal masses with an imperative indication for NSS, allow planning of the surgical strategy on the basis of the anatomical characteristics of the organ in which the tumor is growing. Patient summary: Three-dimensional models help in defining the best surgical strategy for kidney tumors, especially for complex tumors that require surgery to spare as much of the kidney as possible.