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Purpose We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event. Materials and Methods Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion. Results The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p <0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p <0.01) and 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 hilar location) score (9 vs 8, p <0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96–0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22–1.7, p <0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short-term oncologic outcomes but better renal functional preservation (p <0.01). Conclusions At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion. [ABSTRACT FROM AUTHOR]

Purpose We sought to identify patterns and predictors of recurrence in patients with clinically localized renal cell carcinoma managed by partial nephrectomy. Materials and Methods We performed a retrospective study of 830 consecutive cases of partial nephrectomy done between 2007 and 2015 for clinically localized renal cell carcinoma at a single institution. Patient demographics and pathological characteristics were correlated with recurrence patterns (overall, local and distant) and overall survival using Kaplan-Meier and Cox regression analyses. Differences in the recurrence patterns were evaluated. Results Median patient age was 61 years and median tumor size was 3.1 cm. Overall, 11.6% of tumors were stage pT3, 39.3% were high grade, 2.9% had lymphovascular invasion and 7.1% had positive margins. Higher grade, higher stage, positive surgical margins and increased R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line) score were associated with shorter disease-free survival on Kaplan-Meier analysis. On multivariable regression pT (p <0.01), grade (p <0.01) and R.E.N.A.L. score (p = 0.03) remained independent predictors of disease-free survival. Predictors of metastasis were pT stage (HR 4.5) and grade (HR 3.9, both p <0.01), while R.E.N.A.L. score (HR 3.2, p = 0.03) was the single predictor of local recurrence. Five-year disease-free and overall survival probabilities were 91% and 94%, respectively. Local recurrence manifested and developed earlier than metastasis (median 13 vs 22 months, p <0.01). Conclusions High pT stage, high grade and high R.E.N.A.L. score increase the risk of disease recurrence after partial nephrectomy. The pT stage and grade are predictors of metastasis, while R.E.N.A.L. score predicts local recurrence. Because relapse features and risk factors differ between the 2 recurrence patterns, they should be studied separately in the future. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Describe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB). Methods: A MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis. Results: A total of six articles evaluating the efficacy and safety of Botox® in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10–12U/kg with a maximal dose of 300U, usually as 30 injections of 10U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65–87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40cmH2O and compliance was increased >20ml/cmH2O) variables, without major adverse events. Conclusions: Botox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics. [Copyright &y& Elsevier]

At Republic 462a-e, Plato provides an account of political unity summarized in the following claims: PU1 — Political unity is the sharing of pleasures and pains in common; PU2 — The unity of a polis resembles the unity of an individual; PU3 — Political unity is the greatest good for a polls. Aristotle criticizes the coherence of these claims arguing that if anything becomes completely unified it becomes an individual and ceases to be a state. Since the greatest good for a city preserves it. a city cannot be unified as an individual is unified. Robert Mayhew has recently defended the philosophical significance of Aristotle's objections. Mayhew is right. Aristotle's objections are significant, but this is because they require a more thorough explication of the Platonic view. This paper reconstructs the Platonic view, shows that a more careful reading avoids the Aristotelian criticisms, and then shows that Aristotle endorses the reconstructed view. [ABSTRACT FROM AUTHOR]

Abstract: INTRODUCTION: Isolated vasculitis of the bladder is extremely rare. The main causes of which are auto-immune diseases and occasionally infections. Corticosteroid therapy plays a central role in treatment in the majority of cases. PRESENTATION OF CASE: We report a case of gross hematuria associated with irritative low urinary tract symptoms (LUTS) and an increase of biological parameters of inflammation. Radiologic studies suspected a pelvic tumor process. We performed a cystoscopy with multiple biopsies. The pathological findings of the chips were in favor of a thrombotic nongranulomatous vasculitis of small and medium caliber. In view of these findings, all systemic diseases and inflammatory diseases such as cryoglobulinemia, the anti-phospholipid syndrome, Crohn's disease were eliminated. The symptoms regressed completely under antibiotics and anticoagulants. DISCUSSION: Our treatment options were based on the extent of the acute phase reaction and the pelvic venous thrombosis. A few similar cases have been reported in the literature, particularly a case of isolated necrotizing vasculitis of the bladder involving small vessels with a mild laboratory acute phase reaction which was treated with corticosteroids and cyclophosphamide. CONCLUSION: It is important to differentiate this rare pathological feature of the bladder from other bladder tumors as the treatment is medical rather than surgical. [Copyright &y& Elsevier]

Objective: To evaluate the prognostic value of programmed death ligand-1 (PD-L1) and programmed death-1 (PD-1) expression in patients with upper tract urothelial carcinoma (UTUC)., Patients and Methods: A retrospective multicentre study was conducted in 283 patients with UTUC treated with radical nephroureterectomy (RNU) between 2000 and 2015 at 10 French hospitals. Immunohistochemistry analyses were performed using 2 mm-core tissue microarrays with NAT105® and 28.8® antibodies at a 5% cut-off for positivity on tumour cells and tumour-infiltrating lymphocytes to evaluate PD-L1 and PD-1 expression, respectively. Multivariable Cox regression models were used to determine the independent predictors of recurrence-free (RFS), cancer-specific (CSS) and overall survival (OS)., Results: Overall, 63 (22.3%) and 220 (77.7%) patients with UTUC had PD-L1-positive and -negative disease, respectively, while 91 (32.2%) and 192 (67.8%) had PD-1-positive and -negative disease, respectively. Patients who expressed PD-L1 or PD-1 were more likely to have pathological tumour stage ≥pT2 (68.3% vs 49.5%, P = 0.009; and 69.2% vs 46.4%, P < 0.001, respectively) and high-grade (90.5% vs 70.0%, P = 0.001; and 91.2% vs 66.7%, P < 0.001, respectively) disease with lymphovascular invasion (52.4% vs 17.3%, P < 0.001; and 39.6% vs 18.2%, P < 0.001, respectively) as compared to those who did not. In multivariable Cox regression analysis adjusting for each other, PD-L1 and PD-1 expression were significantly associated with decreased RFS (hazard ratio [HR] 1.83, 95% confidence interval [CI] 1.09-3.08, P = 0.023; and HR 1.59, 95% CI 1.01-2.54, P = 0.049; respectively), CSS (HR 2.73, 95% CI 1.48-5.04, P = 0.001; and HR 1.96, 95% CI 1.12-3.45, P = 0.019; respectively) and OS (HR 2.08, 95% CI 1.23-3.53, P = 0.006; and HR 1.71, 95% CI 1.05-2.78, P = 0.031; respectively). In addition, multivariable Cox regression analyses evaluating the four-tier combination of PD-L1 and PD-1 expression showed that only PD-L1/PD-1-positive patients (n = 38 [13.4%]) had significantly decreased RFS (HR 3.07, 95% CI 1.70-5.52; P < 0.001), CSS (HR 5.23, 95% CI 2.62-10.43; P < 0.001) and OS (HR 3.82, 95% CI 2.13-6.85; P < 0.001) as compared to those with PD-L1/PD-1-negative disease (n = 167 [59.0%])., Conclusions: We observed that PD-L1 and PD-1 expression were both associated with adverse pathological features that translated into an independent and cumulative adverse prognostic value in UTUC patients treated with RNU., (© 2023 BJU International.)

Purpose: We investigated the association between preoperative proteinuria and early postoperative renal function after robotic partial nephrectomy (RPN)., Patients and Methods: We retrospectively reviewed 1121 consecutive RPN cases at a single academic center from 2006 to 2016. Patients without pre-existing CKD (eGFR≥60 mL/min/1.73m2) who had a urinalysis within 1-month prior to RPN were included. The cohort was categorized by the presence or absence of preoperative proteinuria (trace or greater (≥1+) urine dipstick), and groups were compared in terms of clinical and functional outcomes. The incidence of acute kidney injury (AKI) was assessed using RIFLE criteria. Univariate and multivariable models were used to identify factors associated with postoperative AKI., Results: Of 947 patients, 97 (10.5%) had preoperative proteinuria. Characteristics associated with preoperative proteinuria included non-white race (p<0.01), preoperative diabetes (p<0.01) and hypertension (HTN) (p<0.01), higher ASA (p<0.01), higher BMI (p<0.01), and higher Charlson score (p<0.01). The incidence of AKI was higher in patients with preoperative proteinuria (10.3% vs. 4.6%, p=0.01). The median eGFR preservation measured within one month after surgery was lower (83.6% vs. 91%, p=0.04) in those with proteinuria; however, there were no significant differences by 3 months after surgery or last follow-up visit. Independent predictors of AKI were high BMI (p<0.01), longer ischemia time (p<0.01), and preoperative proteinuria (p=0.04)., Conclusion: Preoperative proteinuria by urine dipstick is an independent predictor of postoperative AKI after RPN. This test may be used to identify patients, especially those without overt CKD, who are at increased risk for developing AKI after RPN., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Background: Understanding physician-level discrepancies is increasingly a target of US healthcare reform for the delivery of quality-focused patient care., Objective: To estimate the relative contributions of patient and surgeon characteristics to the variability in key outcomes after partial nephrectomy (PN)., Design, Setting, and Participants: Retrospective review of 1461 patients undergoing PN performed by 19 surgeons between 2011 and 2016 at a tertiary care referral center., Intervention: PN for a renal mass., Outcomes Measurements and Statistical Analysis: Hierarchical linear and logistic regression models were built to determine the percentage variability contributed by fixed patient and surgeon factors on peri- and postoperative outcomes. Residual between- and within-surgeon variability was calculated while adjusting for fixed factors., Results and Limitations: On null hierarchical models, there was significant between-surgeon variability in operative time, estimated blood loss (EBL), ischemia time, excisional volume loss, length of stay, positive margins, Clavien complications, and 30-d readmission rate (all p<0.001), but not chronic kidney disease upstaging (p=0.47) or percentage preservation of glomerular filtration rate (p=0.49). Patient factors explained 82% of the variability in excisional volume loss and 0-32% of the variability in the remainder of outcomes. Quantifiable surgeon factors explained modest amounts (10-40%) of variability in intraoperative outcomes, and noteworthy amounts of variability (90-100%) in margin rates and patient morbidity outcomes. Immeasurable surgeon factors explained the residual variability in operative time (27%), EBL (6%), and ischemia time (31%)., Conclusions: There is significant between-surgeon variability in outcomes after PN, even after adjusting for patient characteristics. While renal functional outcomes are consistent across surgeons, measured and unmeasured surgeon factors account for 18-100% of variability of the remaining peri- and postoperative variables. With the increasing utilization of value-based medicine, this has important implications for the goal of optimizing patient care., Patient Summary: We reviewed our institutional database on partial nephrectomy performed for renal cancer. We found significant variability between surgeons for key outcomes after the intervention, even after adjusting for patient characteristics., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction and Objective: Partial nephrectomy (PN) represents the current surgical standard for T1 tumors. Renal arterial pseudoaneurysm is a rare but potentially life-threatening complication reported after PN. The aim of this study was to identify the factors associated with the occurrence of pseudoaneurysm after PN, specifically focusing on those requiring management with selective embolization. A literature review of the topic was performed., Methods: A retrospective review of the institutional PN database was performed from January 2011 to December 2016. Patients who underwent embolization for pseudoaneurysm represented a separated cohort to be compared with other patients (controls). Patients' and tumors' characteristics were considered. Univariable and multivariable analyses were used to test their eventual association with the occurrence of pseudoaneurysm., Results: A total of 1417 cases were evaluated. At a median of 21 days (interquartile range = 10-34), 20 patients (1.4%) developed postoperative pseudoaneurysm. The majority of patients (70%) presented with gross hematuria. The clinical suspicion was confirmed by contrast-enhanced computed tomography scan with angiography. Selective embolization was performed using endovascular coils. Technical success and clinical success rates were 100% and 95%, respectively. No difference was found in percentage estimated glomerular filtration rate (eGFR) preserved between patients who underwent embolization versus controls (median 82.6% versus 86.3%, P = .35). No differences in age, baseline renal function (as assessed by glomerular filtration rate [GFR]), tumor size, and R.E.N.A.L. were found between patients who reported and did not report pseudoaneurysm. In patients who developed pseudoaneurysm, longer operative time (225.6 minutes versus 193 minutes, P = .04), and cold ischemia time (48 minutes versus 29 minutes, P = .03) were reported., Conclusion: In our series, the occurrence of pseudoaneurysm was associated with longer operative and cold ischemia times. In patients who underwent selective embolization, renal function remained comparable with that of controls.

Objective: To identify preoperative factors that predict positive surgical margins in partial nephrectomy., Material and Methods: Using our institutional partial nephrectomy database, we investigated the patients who underwent partial nephrectomy for malignant tumors between January 2011 and December 2015. Patient, tumor, surgeon characteristics were compared by surgical margin status. Multivariable logistic regression was used to identify independent predictors of positive surgical margins., Results: A total of 1025 cases were available for analysis, of which 65 and 960 had positive and negative surgical margins, respectively. On univariate analysis, positive margins were associated with older age (64.3 vs. 59.6, p<0.01), history of prior ipsilateral kidney surgery (13.8% vs. 5.6%, p<0.01), lower preoperative eGFR (74.7 mL/min/1.73 m 2 vs. 81.2 mL/min/1.73 m 2 , p=0.01), high tumor complexity (31.8% vs. 19.0%, p=0.03), hilar tumor location (23.1% vs. 12.5%, p=0.01), and lower surgeon volume (p<0.01). Robotic versus open approach was not associated with the risk of positive margins (p=0.79). On multivariable analysis, lower preoperative eGFR, p=0.01), hilar tumor location (p=0.01), and lower surgeon volume (p<0.01) were found to be independent predictors of positive margins., Conclusion: In our large institutional series of partial nephrectomy cases, patient, tumor, and surgeon factors influence the risk of positive margins. Of these, surgeon volume is the single most important predictor of surgical margin status, indicating that optimal oncological outcomes are best achieved by high-volume surgeons.

Introduction: We evaluated the influence of perinephric fat invasion (PFI) compared with sinus fat invasion (SFI) on disease-free survival (DFS) and cancer-specific survival (CSS) after partial nephrectomy (PN) for stage pT3a renal cell carcinoma (RCC)., Materials and Methods: Data were recorded from the consecutive records of patients who had undergone underwent PN for cT1-T2 RCC from 2007 to 2016. Of these patients, 143 had stage pT3a with SFI or PFI found on final pathologic examination. The demographic, perioperative, and pathologic variables were reviewed. DFS and CSS analyses were performed. The factors predicting disease progression in this population were assessed., Results: After a median follow-up period of 28 months (range 15-41 months), 19 patients (13.3%) had developed recurrence, including 5 local and 14 distant metastases, with 11 cancer-specific deaths (7.7%). No differences were found in DFS (5 years, 60.9% vs. 55.3%; log-rank P = .7) or CSS (5 years, 81% vs. 74.2%; log-rank P = .8) between the SFI and PFI groups. For the pT3a fat invasion population, the 2- and 5-year DFS and CSS rates were 83.6% and 58.6% and 93.6% and 78%, respectively. SFI (P = .5) and positive surgical margins (P = .1) did not predict for progression. On multivariate Cox regression, increased tumor size (hazard ratio, 1.5; 95% confidence interval, 1.1-1.9; P < .01) and higher tumor grade (hazard ratio, 3.6; 95% confidence interval, 1.1-4.6; P = .04) were independent predictors of disease progression in the pT3a fat invasion population., Conclusion: In our series of patients with pT3a RCC after PN, SFI compared with PFI was not associated with an increased risk of progression or cancer-specific death., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Frozen sections (FS) are routinely employed to assess margin status during partial nephrectomy (PN) for clinically localized renal cell carcinoma (CLRCC); however, their oncologic benefit remains unclear. There have been no studies investigating the long-term impact of FS on local or metastatic recurrence. We wished to determine whether the utilization of FS for this purpose during PN influenced recurrence rates., Materials and Methods: We performed a retrospective review of 1090 patients with (n = 172) and without (n = 918) FS during open and robotic PN between 2006 and 2016 for CLRCC at a single tertiary care institution. Standard follow-up protocols were employed, with imaging used to guide subsequent biopsy for confirmation. Univariate and multivariate competing-risk regression analysis predicting the association of FS status and clinicodemographic characteristics with recurrence, with adjustment for all-cause mortality, were performed. Administrative data were reviewed to calculate costs of FS., Results: Forty-five out of 1090 (4.13%) patients had recurrence. There was no difference in the cumulative incidence of recurrence between patients with and without FS (χ 2  = 0.001, p = 0.97). On multivariable competing risk analysis, FS was not associated with recurrence (hazard ratio [HR], 1.56; 95% confidence interval [CI], 0.65-3.76). However, tumor grade (g3-4 vs 1-2: HR, 2.45; 95% CI, 1.16-5.14) and stage (>pT2 vs pT1a: HR, 2.86; 95% CI, 1.13-7.26) were associated with recurrence. The average direct charge per patient undergoing FS was $902., Conclusions: Intraoperative FS for margins during PN did not predict decreased recurrence rates in a single-institution high-volume center. Given the lack of associated benefit, and the added cost, the utilization of FS during PN should be limited.

Objectives: To report a comparative analysis of outcomes in patients who underwent multiple excisions for unilateral synchronous multifocal renal tumors using both open and robotic approaches., Methods: We retrospectively reviewed 110 patients who underwent robotic and open partial nephrectomy and had multiple tumor excisions in an ipsilateral kidney. "Trifecta" was defined as negative surgical margins, no urologic complications, and a glomerular filtration rate (GFR) preservation of ≥90% at last follow-up. Inverse probability of treatment weighting (IPTW) was applied to equilibrate treatment groups, minimize selection bias, and optimize inference on the basis of each patient's clinicodemographic characteristics., Results: Sixty-eight robotic and 42 open patient approaches had sufficient data for IPTW. After weighting, there were no statistical differences in baseline characteristics between the two groups. On adjusted analyses, robotic partial nephrectomy achieved equivalent rates of trifecta to open surgery (16.3% vs 16.5%, p = 0.99), which persisted on subgroup analyses of patients with two (20.1% vs 23.7%, p = 0.82) or more than two tumors (6.8% vs 7.4%, p = 0.95). There were no differences between robotic and open cohorts for negative margin rates, absence of complications, or GFR ≥90%. The robotic cohort had a shorter mean length of stay (3.4 vs 4.9 days, p < 0.001)., Conclusions: Surgical resection remains the mainstay for patients with unilateral, synchronous, and multifocal renal tumors. Our analysis found that both open and robotic approaches to partial nephrectomy are equally likely to achieve the "trifecta" outcome in an equilibrated high-risk group of patients. The robotic approach for these complex patients may be safe and feasible for a carefully selected group of patients.

Aims: To assess the impact of sacral neuromodulation (SNM) on pregnancy and vice-versa, by identifying women who had received SNM for lower-urinary tract symptoms (LUTS) and had become pregnant., Methods: A cross-sectional descriptive study was carried out based on responses to an on-line questionnaire sent to practitioners listed on the InterStim enCaptureTM National Registry. Questions were related to pre-pregnancy health and SNM efficacy, deactivation of the device, its impact on LUTS, childbirth, the infant, its reactivation and postpartum effectiveness., Results: Twenty-seven pregnancies were recorded among 21 women. Six women had had a pregnancy prior to implantation, two of whom had had a c-section. A total of 18.5% of women had the device disabled prior to conception. The others had their device disabled during the first trimester and did not reactivate it before delivery. Complications were reported in 25.9% of pregnancies: six women had urinary infections, including three of the four treated for chronic retention of urine (CRU), and 1 woman had pain at the stimulation site. There were 24 live births (including one premature birth and four c-sections), one spontaneous miscarriage and two voluntary interruptions of pregnancy. No neonatal disorders have been reported. Effectiveness of sacral neuromodulation decreased in 20% in postpartum., Conclusions: In 27 pregnancies established during SNM for LUTS, 18.5% of patients deactivated their case before pregnancy and the others switched it off during the first trimester. Three-quarters of women with CRU had urinary infection. No adverse effects on fetuses were found. SNM effectiveness deteriorated in 20% cases after childbirth., (© 2017 Wiley Periodicals, Inc.)

Introduction: A renorrhaphy technique which is effective for hemostasis but does not place undue tension on the branch vessels of the renal sinus remains one of the challenging steps after hilar tumor resection during robotic partial nephrectomy (RPN). The published V-hilar suture (VHS) technique is one option for reconstruction after an RPN involving the hilum. The objective of this video is to show a novel renorrhaphy technique, Hilar Parenchymal Oversew that has been effective for such cases., Materials and Methods: We present two cases of RPN for renal hilar tumors. The first case depicts use of the VHS renorrhaphy technique for a tumor that abuts the renal hilum along 20% of its diameter. The second case demonstrates tumor resection and reconstruction for a tumor that has >50% involvement of the hilum along its diameter. After tumor resection, individual sinus vessels can be selectively oversewn with 2-0 Vicryl suture on SH needle. The remaining exposed parenchyma is controlled using the Hilar Parenchymal Oversew technique with a #0 Vicryl on CT-1 needle., Results: For the Hilar Parenchymal Oversew surgery operative time was 225 min, estimated blood loss was 140 ml, warm ischemia time was 19 minutes, and there were no intraoperative complications. Pathology was consistent with clear cell renal cancer with negative margins., Conclusion: Robotic partial nephrectomy with the Hilar Parenchymal Oversew technique is a good alternative to VHS renorrhaphy in the management of renal hilar tumors "bulging" into the renal sinus with >50% of the tumor diameter abutting the hilum., Competing Interests: Conflict of interest: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Objectives: The aim of this study was to analyze the outcomes of surveillance after partial nephrectomy (PN) in a single institution and the relevance of imaging studies in detecting recurrence., Material and Methods: Retrospective study of 830 patients who underwent PN for localized renal cell carcinoma between 2007 and 2015 at a single institution. We studied the characteristics of recurrence according to pathological and clinical features and elaborated risk groups. The type and the total number of imaging studies performed during surveillance or until recurrence were evaluated. Outcomes of surveillance were analyzed., Results: There were 48 patients (5.8%) diagnosed with recurrence during median 36 [21-52] months follow-up, including local recurrence in 18 patients (37.5%) and metastasis in 30 patients (62.5%). Totally, 17/18 patients (94.4%) with local recurrence and 26/30 patients (86.6%) with metastasis were diagnosed within the first 36 months after PN. When studying the recurrence rate, and time-to-recurrence, 2 risk groups emerged. Patients with pathological characteristics (tumors with pT1b or higher or high-grade tumor or positive surgical margin status) or patients with anatomical characteristics (high or moderate R.E.N.A.L. score) or both had high recurrence rate. Chest x-ray and abdominal ultrasound detected 7.7% and 3.4% of all recurrences, respectively, whereas computed tomography scan and magnetic resonance imaging scan detected the rest. Of the 48 patients diagnosed with recurrence, 44 (91.6%) were suitable for secondary active treatment (systemic, surgery, and radiotherapy) including 26 (54.2%) suitable for metastasectomy. The rate of relapse after secondary treatment was 43.5% (16.6% for the local recurrence group and 60.7% for metastasis group)., Conclusion: Local recurrence emerges earlier than distant metastasis. Patients with any adverse pathological or anatomical features should be considered as high-risk group and followed closely in the first 36 months after PN with cross-sectional studies. Secondary active treatment is suitable for most patients, while surgical treatment fits fewer patients. Local recurrence is associated with increased rates of metastatic progression., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To examine the dynamic and potentially synergistic influence of warm ischemia time (WIT) and excisional volume loss (EVL) on predicted rates of postpartial acute kidney injury (AKI) across a range of tumor complexities, and to investigate whether these modifiable variables sensitize the kidney to each other's damaging influence., Materials and Methods: We retrospectively reviewed 1245 patients between 2006 and 2016 with bilateral kidneys and enhancing renal masses in our single-institution robotic partial nephrectomy (PN) database. EVL was calculated as the difference between specimen and tumor volume based on pathologic measurements. Multivariate logistic regressions, followed by marginal effects, were run to examine the interaction of ischemia type, EVL, and radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line score on rates of AKI., Results: We found a significant interaction effect of WIT and log EVL on predicted AKI (P < .001). Each doubling of EVL caused a 4.03% and 8.46% increased probability of AKI for WIT of <25 and >25 minutes, respectively. At an EVL of >5.5 cm 3 , prolonged WIT had statistically greater odds of causing AKI. These predicted effects on AKI were amplified for increasing radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line scores (P < .001)., Conclusion: Although the adverse functional effects of WIT and parenchymal volume loss during PN have previously been described in isolation, our findings suggest that their influence on AKI is synergistic, especially in complex tumors. As such, additional attention should be given to limiting warm ischemia and maximizing surgical precision to avoid a "double hit" on postoperative renal function., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Renal function after partial nephrectomy (PN) may depend on modifiable factors including ischemia time, excision of healthy parenchyma (excisional volume loss, EVL), and reconstructive methods. We retrospectively reviewed our institutional robotic PN database to identify the predictors of glomerular filtration rate (GFR) preservation (GFR-P) at 3-12 mo postoperatively, during which GFR decline plateaus. Baseline clinical, sociodemographic, and radiologic characteristics were captured. Univariate and multivariate (MV) linear regression analyses were performed and marginal effects were employed to examine the relative effect of EVL on renal function. A total of 647 patients who underwent robotic PN had GFR data at a median follow-up of 6 mo. On MV models, EVL was significantly correlated with GFR-P following log transformation (p=0.001). Each doubling of EVL caused a 1.5% decrease in GFR-P. Ischemia time and tumor complexity were not significantly associated with GFR-P. In summary, GFR-P after PN appears to be significantly associated with the excised volume of benign parenchyma., Patient Summary: At a high-volume tertiary care center, we investigated the impact of surgical factors on kidney function after kidney cancer surgery. We found that the surgical precision with which the tumor is excised significantly impacts kidney function at 3-12 mo after surgery., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

The CIC-DUX4 sarcoma is a subset of the undifferentiated small round cell sarcoma family, presently recognized as a new clinicopathological entity. It is a rare and highly aggressive tumor usually arising in the soft parts of the limbs and the trunk. Only a very few cases of primitive visceral CIC-DUX4 have been hitherto described. We report the case of a 29 year-old male patient with a primary CIC-DUX4 sarcoma of the kidney with lung metastasis. The outcome of the disease was rapidly unfavorable. Despite radical nephrectomy, the patient experienced an early local retroperitoneal recurrence associated with lung and liver metastases. The tumor did not respond to four successive lines of chemotherapy nor to palliative radiotherapy. Due to partial morphologic and immunohistochemical overlap with Ewing sarcoma, CIC-DUX4 positive tumors have generally been considered as Ewing-like sarcomas and managed similarly. However, this tumor shows a high propensity to metastasize and is much less sensitive to chemotherapy than Ewing sarcomas. The management of this type of very aggressive sarcoma needs to be defined by comprehensive biological and clinical studies., (Copyright © 2016 Elsevier GmbH. All rights reserved.)

Objectives: To assess the impact of approach on surgical outcomes in otherwise healthy obese patients undergoing partial nephrectomy for small renal masses., Patients and Methods: Using our institutional partial nephrectomy database, we abstracted data on otherwise healthy (Charlson comorbidity score ≤1 and bilateral kidneys), obese patients (body mass index >30 kg/m 2 ) with small renal masses (<4 cm) treated between 2011 and 2015. The primary outcomes were intra-operative transfusion, operating time, length of hospital stay (LOS), and postoperative complications. The association between approach, open (OPN) vs robot-assisted partial nephrectomy (RAPN), and outcomes was assessed by univariable and multivariable logistic regression analyses. Covariates included age, gender, obesity severity, tumour size and tumour complexity., Results: Of 237 obese patients undergoing partial nephrectomy, 25% underwent OPN and 75% underwent RAPN. Apart from larger tumour size in the OPN group (2.8 vs 2.5 cm; P = 0.02), there was no significant difference between groups. The rate of intra-operative blood transfusion (1.1 vs 10%; P = 0.01), the median operating time (180 vs 207 min; P < 0.01) and the median ischaemia time (19.5 vs 27 min; P < 0.01) were all greater for OPN. The LOS was significantly shorter for RAPN (3 vs 4 days; P < 0.01). While the overall complication rate was higher for OPN (15.8 vs 31.7%; P < 0.01), major complications were not significantly different (5.6 vs 1.7%; P = 0.20). On multivariable analyses, OPN independently predicted longer operating time, longer length of stay, and more overall complications., Conclusions: At a high-volume centre, the robot-assisted approach offers less blood transfusion, shorter operating time, faster recovery, and fewer peri-operative complications compared with the open approach in obese patients undergoing partial nephrectomy for small renal masses. In this setting, RAPN may be a preferable treatment option., (© 2016 The Authors BJU International © 2016 BJU International Published by John Wiley & Sons Ltd.)

Objective: To evaluate the long-term results of patients surgically treated for metastatic clear cell renal cell carcinoma (CCRCC) with a unique pancreatic secondary localization to assess the importance of radical treatment in this rare group of patients., Patients and Methods: This is a retrospective monocentric study including 20 surgically treated patients between 1997 and 2012 for a unique pancreatic metastasis of a CCRCC. The main objective was to evaluate the outcome after surgical resection., Results: Twenty patients were followed up for a CCRCC. The M/F ratio was 1.2. The average age of onset of kidney cancer was 57.05 ± 7.78 years. Two patients who had synchronous pancreatic metastasis and 18 patients who had metachronous metastasis appeared after an average of 130 ± 59 months (24-240 months). The average size of the metastases was 20 ± 11.6 mm. Pancreatic metastasis was unique in all patients, with 35% of patients having multiple lesions of the pancreas. All patients underwent a pancreatic resection of metastasis. Histologic examination confirmed the location of a secondary CCRCC in all patients. Median follow-up after pancreatectomy was 69 months (1-150 months). Disease-free survival at 2 years was 60%. Overall survival rates at 2 and 4 years were 79% and 72%, respectively. There was no difference found between patients with multiple and unique pancreatic metastases in overall survival., Conclusion: Unique pancreatic metastasis of CCRCC is rare. The literature on this subject is limited. Surgical resection might be an option and can be associated with long-term disease-free intervals in highly selected patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To assess the use of local haemostatic agents (HAs) in a prospective multicentre large series of partial nephrectomies (PNs)., Patients and Methods: Prospective National Observational Registry on the Practices of Haemostasis in Partial Nephrectomy (NEPHRON): the study was conducted in 54 French urological centres from 1 June to 31 December 2010. In all, 570 consecutive patients undergoing a PN were enrolled in this study in a prospective manner. The data was collected prospectively via an electronic case-report form: five different sheets were included for preoperative, perioperative, postoperative and follow-up data respectively. Information related to haemostasis was analysed., Results: The median patient age was 60 years and the mean (range) tumour size was 3.68 (0.19-15) cm. An HA was primarily used in 71.4% of patients, with a statistically significant difference among surgical approaches (P = 0.024). In 91.8% of cases, a single use of a HA was sufficient for achieving haemostasis. The HA was used either alone (13.9%) or in association with sutures (80.3%). One or more additional haemostatic action(s) was needed in 12.3% of the cases. When comparing patients who received a HA with those who did not receive a HA, there was no statistical difference between the groups for tumour size (P = 0.542), collecting system drainage (P = 0.538), hospital stay (P = 0.508), operation time (P = 0.169), blood loss (P = 0.387) or transfusion rate (P = 0.713)., Conclusion: HAs are widely used by urologists during PN. Progress is needed for standardising HA application, especially for the timing of application. For the time being, the role of the HA in nephron-sparing surgery is still to be evaluated., (© 2013 The Authors. BJU International © 2013 BJU International.)

Introduction: The effects of intracavernous alprostadil injection (IAI), a primary treatment for post-radical prostatectomy (RP) erectile dysfunction (ED) (pRPED), on the sex life of women partnered with men who have undergone RP have received little attention., Aims: The aim of this study is to investigate the sexual quality of life in female partners of men receiving IAIs for pRPED., Methods: We retrospectively studied the sex lives of 152 women partnered with men who were being treated for pRPED with IAI and previously had normal erectile function. Women completed the Index of Sexual Life (ISL) questionnaire 1 year after their partner's RP. Male patients completed the International Index of Erectile Function (IIEF-15), the Erection Hardness Score (EHS) questionnaire, the International Consultation on Incontinence Questionnaire (ICIQ), and the UCLA Prostate Cancer Index (UCLA-PCI) urinary function questionnaire. Penile pain was assessed using the visual analog scale (VAS). Statistical analysis was performed using t-tests, Spearman correlation, and multiple linear regression., Main Outcome Measures: Female sexual life satisfaction (SLS), sexual drive (SD), and general life satisfaction (GLS) were assessed using the ISL questionnaire., Results: Mean ages for the 104 couples included were 62.3 and 59.8 years for the men and women, respectively. Mean ISL, SD, SLS, and GLS scores at 12 months were 25.4, 3.8, 14.1, and 7.5, respectively. ISL scores were strongly correlated with IIEF-15 domains, mainly erectile function (r > 0.41, P < 0.00002) and intercourse satisfaction (r > 0.27, P < 0.005). Age and VAS, ICIQ, and UCLA-PCI scores were negatively correlated with some ISL domains. IIEF-15 erectile function and intercourse satisfaction were the most significant domains predicting female SLS. An IIEF-15 erectile function of 25 corresponded to a 75% chance of an SLS score ≥18., Conclusion: Indexes of female sexual quality of life were low overall but were highly correlated with the partner's response level to IAI treatment. IAI-related pain, increased age, and poor urinary function of the male partner appear to negatively impact female sex life., (© 2013 International Society for Sexual Medicine.)

Aim: Our aim was to evaluate the performance of combination of fine-needle aspiration (FNA) and core biopsy (CB) as a method for the diagnosis of small solid renal tumors., Patients and Methods: Ninety patients with a radiologically detected small solid renal tumor (≤ 4 cm) underwent a biopsy. Patient underwent FNA (FNA group, n=32) or CB (CB group, n=30) or combination of both FNA and CB (combination group, n=28). The diagnostic rate and accuracy of both techniques were assessed., Results: The diagnostic rate of the combination group (92.9%) was superior to that of the FNA group (62.5%) and CB group (76.7%) (p=0.006, and p=0.147, respectively). In the combination group, 11 CBs were diagnostic with 13 nondiagnostic FNAs, while 4 FNAs were diagnostic with 6 nondiagnostic CBs. For tumors ≤ 2 cm, the combination of FNA and CB significantly increased the diagnostic rate, compared with FNA alone (p=0.033) and CB alone (p=0.044). The accuracy for FNA, CB and the combination of FNA and CB was 88%, 100% and 100%, respectively., Conclusion: The combination of FNA and CB increased the diagnostic rate of renal biopsy for the small solid renal tumors.

Introduction: This study aims to assess the influence of different prognostic factors on survival of upper tract urothelial carcinoma (UTUC) managed by nephroureterectomy and to investigate whether these factors have an independent prognostic significance., Materials and Methods: A retrospective review of institutional databases from two teaching hospitals identified 269 consecutive patients with UTUC managed with nephroureterctomy between 1985 and 2005. Mean follow up was 80.6 months (median 70.3 months). Follow up was completed until January 2009. Tumor location and other clinicopathological variables were analyzed regarding survival. Data accrued included age, gender, tumor characteristics (pT stage, grade, lymph node status), tumor location, use of chemotherapy and period of diagnosis. Tumor location was divided into two groups (renal pelvis and ureter) based on the location of the tumor., Results: Five year and 10 year overall survival estimates for this cohort were 71.3% and 40.0% respectively. According to tumor location, survival was 73.6% and 47.0% for the renal pelvis versus 67.8% and 32.3% for the ureter, respectively (log rank test: p = 0.027). In multivariate analysis, among the clinicopathological variables, T stage was the most significant prognostic factor (p < 0.001). Nodal involvement (p = 0,005), high grade (p < 0.001), first period of diagnosis (p < 0.001) and ureteral tumor location (p = 0.003) were significantly associated with lower survival rates. Prognosis of UTUC improved over time: survival was significantly better during the last period of diagnosis (2001-2005) (p < 0.002)., Conclusions: Tumor location and diagnostic period should be considered as an independent prognostic factor for upper tract transitional cell carcinoma.

Study Type: Therapy (case series)., Level of Evidence: 4. What's known on the subject? and What does the study add? Despite excellent surgical cancer control, up to 40% of patients will have biochemical recurrence following radical prostatectomy (RP) for localized prostate cancer. Positive surgical margins (PSM) have been clearly demonstrated to be one of the main predictive factors for biochemical failure, disease progression and cancer mortality. However, decision of further management (adjuvant or salvage therapy) in patients with PSM remains controversial, and many debatable questions arise concerning the incidence of clinical progression and the impact of systematic adjuvant treatment on the cancer specific and overall survival. Analysis of the pathological and disease recurrence outcomes of our large cohort of patients treated by RP provides evidence that PSMs are associated with a poor prognosis in terms of PSA failure and need for salvage therapy. However, such a distinction between negative or positive margin cancers seems to appear clinically less relevant in locally advanced disease with seminal vesicle or high Gleason score≥8 due to the predominant significance of these two poor prognosis factors for prediction of PSA failure., Objective: To study the impact of positive surgical margins (PSMs) as an independent predictor of prostate-specific antigen (PSA) failure after radical prostatectomy in adjuvant treatment-naïve patients., Patients and Methods: From 2000 to 2008, 1943 men who underwent a radical prostatectomy at Henri Mondor Hospital and who did not receive neoadjuvant or adjuvant therapy were included. Follow-up was recorded into a prospective database. Mean follow-up was 68.8 months. The biochemical recurrence-free survival (RFS), defined by a PSA>0.2 ng/mL, and the need for salvage therapy in univariate and multivariate models, were evaluated., Results: PSA failure was reported in 14.7% and PSMs were noted in 25.6%. In the overall cohort, PSM was significantly predictive for PSA failure (P<0.001; hazard ratio, HR, 2.6), need for salvage therapy (P<0.001; HR, 2.9) and specific deaths (P=0.006; HR, 3.7). The 5-year RFS was 84.4% in men with negative margins compared to 57.5% in the case of PSM. After stratification by pathological stage and Gleason score, margin status was significantly predictive for PSA failure in pT2 (P<0.001), pT3a (P=0.001) and/or Gleason score≤7 cancers (P<0.001), whereas the impact of PSM did not reach significance in pT3b (P=0.196), pT4 (P=0.061) and/or Gleason score≥8 cancers (P=0.115)., Conclusions: PSMs are associated with a poor prognosis in terms of RFS and the need for salvage therapy. Such a distinction between negative or positive margin cancers appears to be clinically less relevant in locally advanced disease with seminal vesicle or high Gleason score (≥8)., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Objectives: To evaluate the early clinical experience associated with radio-frequency (RF) ablation in patients with solitary adrenal gland metastasis of renal cell carcinoma (RCC)., Methods: A total of 5 patients were treated with RF ablation of adrenal gland metastasis from RCC under computed tomography (CT) guidance between 2006 and 2007. Radiotherapeutics generator (Boston Scientific, Natick, MA) and Radiotherapeutics RF ablation probe with "umbrella" array tip (Boston Scientific, Natick, MA) were used. These patients were contraindicated for surgery due to several associated morbidities. All patients underwent a tumor biopsy before RF. The access was percutaneous in all patients. Tumor control was defined as the absence of contrast enhancement in the tumor on CT. Data were collected in a retrospective manner., Results: Five patients were treated with a RF ablation of the adrenal metastasis. The average age of the patients was 69.4 +/- 11.1 years (57-87), the average time between the radical nephrectomy and the onset of adrenal metastasis was 5.2 +/- 1.3 years (4-7), and average diameter of the tumor was 3.9 +/- 1.4 cm (2-6). A year after RF, four patients had a total necrosis of their tumor on CT and 1 had an active tumor for which the patient received a second course of RF. An abscess of the adrenal gland had occurred in 1 case requiring a percutaneous drainage., Conclusions: The treatment of metastatic adrenal gland with RF broadens the range of treatment of metastatic RCC. The efficacy of this therapeutic modality must be confirmed by larger series with the longest follow-up.

Objectives: Describe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB)., Methods: A MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis., Results: A total of six articles evaluating the efficacy and safety of Botox in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10-12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65-87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H(2)O and compliance was increased >20 ml/cm H(2)O) variables, without major adverse events., Conclusions: Botox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.

Purpose: To evaluate the feasibility and safety of replacing the Double-J stent with a ureteral catheter in tubeless percutaneous nephrolithotomy (PCNL)., Materials and Methods: From August 1998 to February 2007, 33 patients underwent tubeless PCNL for renal calculi by the same surgeon. A retrograde 7F ureteral catheter was placed at the beginning of the surgery in all patients. A nephrostomy tube was not used in any patient. At the end of the procedure, the working tract was electrocauterized using a 26F resectoscope with a rollerball electrode; no hemostatic sealant was used. The ureteral catheter was the sole means of drainage left in place. The incidence and type of complications, the operative time, the length of hospitalization, the rate of transfusion, and the degree of pain were obtained by chart review., Results: In this group of patients, the mean stone burden was 17.25 mm. The mean operative time was 71.5 min. The mean length of hospitalization was 1.9 day (range 1 to 7 days). The mean hemoglobin decrease was 0.8 g/dL. No blood transfusions were needed. The mean visual analog pain intensity scale was 1.87. Complications developed in five (15%) patients, of whom one needed a Double-J stent placement. The complications were pyelonephritis, urinary extravasation, sustained hematuria, and renal colic. The ureteral catheter was removed by postoperative day 1 in 91% of patients., Conclusions: Replacing the Double-J stent with a ureteral catheter in tubeless PCNL is an effective procedure and can be performed in patients with a moderate stone burden. The electrocauterization of the bleeding points at the end of percutaneous renal surgery with a rollerball resectoscope is safe.