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The role of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) was challenged by the results of the CARMENA trial. Here we evaluate the role of CN in mRCC patients, including those receiving modern therapies.We included patients with synchronous mRCC between 2011-2020 from the de-identified nationwide Flatiron Health database. We evaluated 3 groups: systemic therapy alone, CN followed by systemic therapy (up-front CN [uCN]) and systemic therapy followed by CN (deferred CN [dCN]). The primary outcome was median overall survival (mOS) in patients receiving systemic therapy alone vs uCN. Secondary outcome was overall survival in patients receiving uCN vs dCN. First-treatment, landmark and time-varying covariate analyses were conducted to overcome immortal time bias. Weighted Kaplan-Meier curves, log-rank tests and Cox proportional hazards regressions were used to assess the effect of therapy on survival.Of 1,910 patients with mRCC, 972 (57%) received systemic therapy, 605 (32%) received uCN, 142 (8%) dCN and 191 (10%) CN alone; 433 (23%) patients received immunotherapy-based therapy. The adjusted mOS was significantly improved in first-treatment, landmark and time-varying covariate analysis (mOS 26.6 vs 14.6 months, 36.3 vs 21.1 months and 26.1 vs 12.2 months, respectively) in patients undergoing CN. Among patients receiving CN and systemic therapy, the timing of systemic therapy relative to CN was not significantly related to overall survival (HR=1.0, 95% CI 0.76-1.32, p=0.99).Our findings support an oncologic role for CN in select mRCC patients. In patients receiving both CN and systemic therapy, the survival benefit compared to systemic alone was similar for up-front and deferred CN.

Intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) has an incidence of approximately 20%-50%. Studies to date have been composed of mixed treatment cohorts-open, laparoscopic and robotic. The objective of this study is to assess clinicopathological risk factors for intravesical recurrence after RNU for UTUC in a completely minimally invasive cohort.We performed a multicenter, retrospective analysis of 485 patients with UTUC without prior or concurrent bladder cancer who underwent robotic or laparoscopic RNU. Patients were selected from an international cohort of 17 institutions across the United States, Europe and Asia. Univariate and multiple Cox regression models were used to identify risk factors for bladder recurrence.A total of 485 (396 robotic, 89 laparoscopic) patients were included in analysis. Overall, 110 (22.7%) of patients developed IVR. The average time to recurrence was 15.2 months (SD 15.5 months). Hypertension was a significant risk factor on multiple regression (HR 1.99, CI 1.06; 3.71, p=0.030). Diagnostic ureteroscopic biopsy incurred a 50% higher chance of developing IVR (HR 1.49, CI 1.00; 2.20, p=0.048). Treatment specific risk factors included positive surgical margins (HR 3.36, CI 1.36; 8.33, p=0.009) and transurethral resection for bladder cuff management (HR 2.73, CI 1.10; 6.76, p=0.031).IVR after minimally invasive RNU for UTUC is a relatively common event. Risk factors include a ureteroscopic biopsy, transurethral resection of the bladder cuff, and positive surgical margins. When possible, avoidance of transurethral resection of the bladder cuff and alternative strategies for obtaining biopsy tissue sample should be considered.

This AUA Guideline focuses on evaluation/counseling/management of adult patients with clinically-localized renal masses suspicious for cancer, including solid-enhancing tumors and Bosniak 3/4 complex-cystic lesions.The Renal Mass and Localized Renal Cancer guideline underwent an update literature review which resulted in the 2021 amendment. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1[Table: see text]).Great progress has been made regarding the evaluation/management of clinically-localized renal masses. These guidelines provide updated, evidence-based recommendations regarding evaluation/counseling including the evolving role of renal-mass-biopsy (RMB). Given great variability of clinical/oncologic/functional characteristics, index patients are not utilized and the panel advocates individualized counseling/management. Options for intervention (partial-nephrectomy (PN), radical-nephrectomy (RN), and thermal-ablation (TA)) are reviewed including recent data about comparative-effectiveness/potential morbidities. Oncologic issues are prioritized while recognizing the importance of functional-outcomes for survivorship. Granular criteria for RN are provided to help reduce overutilization of RN while also avoiding imprudent PN. Priority for PN is recommended for clinical T1a lesions, along with selective utilization of TA, which has good efficacy for tumors≤3.0 cm. Recommendations for genetic-counseling have been revised and considerations for adjuvant-therapies are addressed. Active-surveillance and follow-up after intervention are discussed in an adjunctive article.Several factors require consideration during counseling/management of patients with clinically-localized renal masses including general health/comorbidities, oncologic-considerations, functional-consequences, and relative efficacy/potential morbidities of various management-strategies.

INTRODUCTION AND OBJECTIVE:Magnetic resonance imaging (MRI) fusion needle biopsy has been shown to outperform systematic biopsy in detecting clinically significant prostate cancer. This study sough...

INTRODUCTION AND OBJECTIVE:Renal mass biopsy (RMB) has the potential to reduce unnecessary treatment by informing care, however, its utilization varies widely amongst providers and institutions. To...

INTRODUCTION AND OBJECTIVE:In efforts to judiciously utilize resources and contain cost, there has been increasing efforts to reduce postoperative length of stay, resulting in several groups promot...

INTRODUCTION AND OBJECTIVE:The management of patients with high risk non-muscle invasive urothelial carcinoma (UC) is complex due to the biological heterogeneity of the disease. The management of m...

INTRODUCTION AND OBJECTIVE:Minority communities disproportionately shouldered poor COVID-19 outcomes, however the impact of the pandemic on prostate cancer (PCa) surgery is unknown. To that end, we...

INTRODUCTION AND OBJECTIVE:Narcotics are prescribed excessively following surgery and may lead to persistent opioid use. As many urologic oncology procedures are performed minimally invasively, an ...

INTRODUCTION AND OBJECTIVE:Utility of lymph node dissection (LND) in localized upper tract urothelial carcinoma (UTUC) is controversial. We evaluated outcomes of LND in patients with UTUC using a m...

INTRODUCTION AND OBJECTIVE:Immune checkpoint inhibitors (ICI) are gaining acceptance in the management of metastatic renal cell carcinoma (mRCC) with four FDA approved regimens to date. However, da...

INTRODUCTION AND OBJECTIVE:The choice between active surveillance (AS) and surgical treatment for patients with newly diagnosed low risk malignancies is complex. To inform this nuanced decision, we...

Purpose:We describe contemporary active surveillance utilization and variation in a regional prostate cancer collaborative. We identified demographic and disease specific factors associated with ac...

We evaluated contemporary practice patterns in the management of small renal masses.We identified 52,804 patients in the NCDB (National Cancer Database) who were diagnosed with a small renal mass (4 cm or less) between 2010 and 2014. Utilization trends of active surveillance, ablation and robotic, laparoscopic and open surgical techniques were compared among all comers, elderly patients 75 years old or older and individuals with competing health risks, defined as a Charlson index of 2 or greater. Multivariable logistic regression models were used to assess factors associated with robotic renal surgery and active surveillance.Surgery remained the primary treatment modality across all years studied, performed in 75.0% and 74.2% of cases in 2010 and 2014, respectively. Although increases in active surveillance from 4.8% in 2010 to 6.0% in 2014 (p0.001) and robotic renal surgery (22.1% in 2010 to 39.7% in 2014, p 0.001) were observed, the increase in the proportion of small renal masses treated with robotic partial and radical nephrectomy was greater than that of active surveillance (82.0% and 63.0%, respectively, vs 25.0%). Subgroup analyses in individuals 75 years old or older, or with a Charlson index of 2 or greater likewise revealed preferential increases in robotic surgery vs active surveillance. On multivariable analysis later year of diagnosis was associated with increased performance of robotic renal surgery compared to active surveillance (2014 vs 2010 OR 1.44, 95% CI 1.20-1.72, p0.001) and nonrobotic procedural interventions (2014 vs 2010 OR 2.59, 95% CI 2.30-2.93, p 0.001).Robotic surgical extirpation has outpaced the adoption of active surveillance of small renal masses. This raises concern that the diffusion of robotic technology propagates overtreatment, particularly among elderly and comorbid individuals.

OBJECTIVES: To develop a clinically actionable predictive model to quantitate the risk of estimated glomerular filtration rate decline to ≤ 45 ml/min/1.73m(2) following radical nephrectomy in order to better inform decisions between radical and partial nephrectomy. PATIENTS AND METHODS: Our prospectively maintained kidney cancer registry was reviewed for patients with pre-operative estimated glomerular filtration rate > 60 ml/min/1.73m(2) who underwent radical nephrectomy for a localized renal mass. New baseline renal function was indexed. We used multivariable logistic regression to develop a predictive nomogram and evaluated it utilizing receiver operating characteristic analysis. Decision curve analysis assessed the net clinical benefit. RESULTS: 668 patients met inclusion criteria. 183 patients (27%) experienced estimated glomerular filtration rate decline to ≤ 45 ml/min/1.73m(2). On multivariable analysis, increasing age (p=0.001), female gender (p~11%. CONCLUSIONS: The decision to perform radical vs. partial nephrectomy is multifaceted. We provide a simple quantitative tool to help identify patients at risk of a post-operative eGFR of ≤ 45 ml/min/1.73m(2) who may be stronger candidates for nephron preservation.

INTRODUCTION AND OBJECTIVE:The mainstay of treatment for patients with RCC IVC-TT is surgical resection; however, surgery is associated with high morbidity rates. Furthermore, many of these patient...

INTRODUCTION AND OBJECTIVE:Upper tract urothelial cell carcinoma (UTUC) is an uncommon malignancy with disparate outcomes. We developed a novel pre-operative morphometric scoring system for predict...

INTRODUCTION AND OBJECTIVE:Cystic renal cell carcinomas (cRCC) are suggested to be clinically indolent. As such, a distinct pathologic staging category for these lesions was recently proposed. Thes...

INTRODUCTION AND OBJECTIVE:Renal mass biopsy (RMB) has not been adopted widely by urologists for the evaluation of small renal mass (SRM) before considering surgical intervention due to concerns fo...

INTRODUCTION AND OBJECTIVE:The identification of imaging characteristics associated with T3a renal cell carcinoma (RCC) can may be challenging on pre-operative imaging. A substantial number of pati...

Inguinal lymphadenectomy remains under performed in patients with invasive penile cancer. Using a large national cancer registry we assessed temporal trends in inguinal lymphadenectomy performance and evaluated the impact of the procedure on survival in patients in whom inguinal lymphadenectomy was an absolute indication (T1b-4 N0/x-1) according to NCCNWe queried the National Cancer Database for all cases of nonmetastatic, T1b-4 N0/x-1 squamous cell carcinoma of the penis from 2004 to 2014. Multivariable logistic regression models adjusting for patient, demographic, and clinicopathological characteristics were used to examine the association between available covariates and receipt of inguinal lymphadenectomy. Cox proportional hazards regression analysis was then done to assess the impact of clinical and pathological variables on overall survival. Propensity score weighted analysis was performed to assess the effect of inguinal lymphadenectomy on overall survival.A total of 2,224 patients met analysis criteria, of whom 606 (27.2%) underwent inguinal lymphadenectomy. Following adjustment the procedure was more likely in younger patients, those who presented with palpable adenopathy (cN1), those treated at an academic facility and those with a more contemporary diagnosis. On survival analysis controlling for all known and measured confounders inguinal lymphadenectomy was associated with improved overall survival (HR 0.79, 95% CI 0.74-0.84, p0.001).At hospitals that report to the National Cancer Database the overall rate of inguinal lymphadenectomy in patients with invasive penile cancer was only 27.2%. Inguinal lymphadenectomy was associated with increased overall survival, justifying the procedure as an important quality metric for performance reporting in patients with invasive penile cancer.

We sought to externally validate a mathematical formula for tumor contact surface area as a predictor of postoperative renal function in patients undergoing partial nephrectomy for renal cell carcinoma.We queried a prospectively maintained kidney cancer database for patients who underwent partial nephrectomy between 2014 and 2016. Contact surface area was calculated using data obtained from preoperative cross-sectional imaging. The correlation between contact surface area and perioperative variables was examined. The correlation between postoperative renal functional outcomes, contact surface area and the R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and tumor touches main renal artery or vein) nephrometry score was also assessed.A total of 257 patients who underwent partial nephrectomy had sufficient data to enter the study. Median contact surface area was 14.5 cmContact surface area correlated with the change in postoperative renal function after partial nephrectomy. It can be used in conjunction with the nephrometry score to counsel patients about the risk of renal functional decline after partial nephrectomy.

This AUA Guideline focuses on evaluation/counseling and management of adult patients with clinically localized renal masses suspicious for cancer, including solid-enhancing tumors and Bosniak 3/4 complex-cystic lesions.Systematic review utilized research from the Agency for Healthcare Research and Quality and additional supplementation by the authors and consultant methodologists. Evidence-based statements were based on body of evidence strength Grade A/B/C (Strong/Moderate/Conditional Recommendations, respectively) with additional statements presented as Clinical Principles or Expert Opinions.Great progress has been made since the previous guidelines on management of localized renal masses were released (2009). The current guidelines provide updated, evidence-based recommendations regarding evaluation/counseling of patients with clinically localized renal masses, including the evolving role of renal mass biopsy. Given great variability of clinical, oncologic and functional characteristics, index patients are not utilized and the panel advocates individualized counseling/management. Management options (partial nephrectomy/radical nephrectomy/thermal ablation/active surveillance) are reviewed including recent data about comparative effectiveness and potential morbidities. Oncologic issues are prioritized while recognizing that functional outcomes are of great importance for survivorship for most patients with localized kidney cancer. A more restricted role for radical nephrectomy is recommended following well-defined selection criteria. Priority for partial nephrectomy is recommended for clinical T1a lesions, along with selective use of thermal ablation, particularly for tumors ≤3.0 cm. Important considerations for shared decision-making about active surveillance are explicitly defined.Several factors should be considered during counseling/management of patients with clinically localized renal masses, including general health/comorbidities, oncologic potential of the mass, pertinent functional issues and relative efficacy/potential morbidities of various management strategies.

INTRODUCTION AND OBJECTIVES:While emerging data suggest feasibility and safety of minimally invasive partial nephrectomy (MIS-PN) for T2a renal mass (T2aRM), comparative analyses to minimally invas...

INTRODUCTION AND OBJECTIVES:Impact of positive margins in partial nephrectomy (PN) is controversial. Conflicting data suggest varying conclusions regarding outcomes and survival. We sought to chara...

INTRODUCTION AND OBJECTIVES:Level 1 evidence shows that mTOR inhibition is associated with clinically significant reductions in tumor size in angiomyolipomas (AMLs) associated with Tuberous Scleros...

INTRODUCTION AND OBJECTIVES:Local recurrence (LR) after extirpative surgery for renal cell carcinoma (RCC) refers to cancer that has recurred at or near the site of the primary tumor. Currently, no...

INTRODUCTION AND OBJECTIVES:The opioid epidemic is a public health threat in the United States. Although there have been numerous studies to suggest the deleterious long term effect of overprescrib...

INTRODUCTION AND OBJECTIVES:Radical Nephrectomy (RN) has been the standard of care for complex and locally advanced renal cell carcinoma (RCC). Partial Nephrectomy (PN) utilization has increased in...

INTRODUCTION AND OBJECTIVES:Most recent AUA guidelines suggest that an expected drop of estimated glomerular filtration rate (eGFR) below 45 ml/min/1.733 upon radical nephrectomy (RN) should guide ...

INTRODUCTION AND OBJECTIVES:Criteria for staging of T1 renal tumors into T1a (≤4cm) and T1b (4cm< and ≤7cm) have remained unchanged since 1997. Advancements in tumor biology have led to great understanding of the heterogeneous potential of T1 renal tumors. We hypothesized that a three-tier classification may more rationally risk stratify T1 renal masses than the current T1a/T1b system.METHODS:Multicenter (UCSD, Emory, Fox Chase Cancer Center, Ospadele San Raffaele) retrospective analysis of patients with cT1 renal cell carcinoma (RCC) undergoing partial or radical nephrectomy. Patients were stratified by tumor size into three groups cT1a (≤2cm, very low risk), cT1b (2cm< and ≤5cm, low risk), and cT1c (5cm< and ≤7cm, intermediate risk). Primary outcome was recurrence-free survival (RFS). Secondary outcome was overall survival (OS). Multivariable Cox Regression analysis (MVA) and Kaplan-Meier analyses (KMA) were utilized for outcomes.RESULTS:4710 patients were stratified into proposed T1 groups (T1a=856, T1...

INTRODUCTION AND OBJECTIVES:The AIM and ReM were recently introduced to objectify fusion biopsy deliverables. The AIM metric affords a quantifiable assessment of when US/MRI fusion targeted biopsy ...