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Background: Long-term renal function after partial nephrectomy (PN) is difficult to predict as it is influenced by several modifiable and nonmodifiable variables, often intertwined in complex relations., Objective: To identify variables influencing long-term renal function after PN and to assess their relative weight., Design Setting and Participants: A total of 457 patients who underwent either robotic ( n  = 412) or laparoscopic PN ( n  = 45) were identified from a multicenter international database., Outcome Measurements and Statistical Analysis: The 1-yr estimated glomerular filtration rate (eGFR) percentage loss (1YPL), defined as the eGFR percentage change from baseline at 1 yr after surgery, was the outcome endpoint. Predictors evaluated included demographic data, tumor features, and operative and postoperative variables. Bayesian multimodel analysis of covariance was used to build all possible models and compare the fit of each model to the data via model Bayes factors. Bayesian model averaging was used to quantify the support for each predictor via the inclusion Bayes factor (BF incl ). High-dimensional undirected graph estimation was used for network analysis of conditional independence between predictors., Results and Limitations: Several models were found to be plausible for estimation of 1YPL. The best model, comprising postoperative eGFR percentage loss (PPL), sex, ischemia technique, and preoperative eGFR, was 207 times more likely than all the other models regarding relative predictive performance. Its components were part of the top 44 models and were the predictors with the highest BF incl . The role of cold ischemia, solitary kidney status, surgeon experience, and type of renorraphy was not assessed., Conclusions: Preoperative eGFR, sex, ischemia technique, and PPL are the best predictors of eGFR percentage loss at 1 yr after minimally invasive PN. Other predictors seem to be irrelevant, as their influence is insignificant or already nested in the effect of these four parameters., Patient Summary: Kidney function at 1 year after partial removal of a kidney depends on sex, the technique used to halt blood flow to the kidney during surgery, and kidney function at baseline and in the early postoperative period., (© 2022 The Author(s).)

Background: Postoperative renal function impairment represents a main limitation for delivering adjuvant chemotherapy after radical nephroureterectomy (RNU)., Objective: To create a model predicting renal function decline after minimally invasive RNU., Design, Setting, and Participants: A total of 490 patients with nonmetastatic UTUC who underwent minimally invasive RNU were identified from a collaborative database including 17 institutions worldwide (February 2006 to March 2020). Renal function insufficiency for cisplatin-based regimen was defined as estimated glomerular filtration rate (eGFR) <50 ml/min/1.73 m 2 at 3 mo after RNU. Patients with baseline eGFR >50 ml/min/1.73 m 2 (n = 361) were geographically divided into a training set (n = 226) and an independent external validation set (n = 135) for further analysis., Outcome Measurements and Statistical Analysis: Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, a nomogram to predict postoperative eGFR <50 ml/min/1.73 m 2 was built based on the coefficients of the least absolute shrinkage and selection operation (LASSO) logistic regression. The discrimination, calibration, and clinical use of the nomogram were investigated., Results and Limitations: The model that incorporated age, body mass index, preoperative eGFR, and hydroureteronephrosis was developed with an area under the curve of 0.771, which was confirmed to be 0.773 in the external validation set. The calibration curve demonstrated good agreement. Besides, the model was converted into a risk score with a cutoff value of 0.583, and the difference between the low- and high-risk groups both in overall death risk (hazard ratio [HR]: 4.59, p < 0.001) and cancer-specific death risk (HR: 5.19, p < 0.001) was statistically significant. The limitation mainly lies in its retrospective design., Conclusions: A nomogram incorporating immediately available clinical variables can accurately predict renal insufficiency for cisplatin-based adjuvant chemotherapy after minimally invasive RNU and may serve as a tool facilitating patient selection., Patient Summary: We have developed a model for the prediction of renal function loss after radical nephroureterectomy to facilitate patient selection for perioperative chemotherapy., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Following partial nephrectomy (PN), it is important to prevent any deterioration in estimated glomerular filtration rate (eGFR). At present there are no evidence-based recommendations on when a nephrology consultation should be requested and how to adjust postoperative management when the risk of renal function decline is high. In an effort to address this void, we used our previously published nomogram to define risk groups for a significant decline in eGFR at 3-15 mo after PN. We used the nomogram-derived probability as the independent variable for the classification and regression tree and identified four risk groups: low (0-10%), intermediate (10-21%), high (21-65%), and very high (65-100%). Overall, 336 (34%), 386 (39%), 243 (24%), and 34 (4%) patients fell in the low, intermediate, high, and very high risk groups, respectively. The rates of significant eGFR decline across the low, intermediate, high, and very high risk groups were 4%, 14%, 29%, and 79%. With the low risk category as a reference, the hazard ratio for eGFR decline was 3.21 (95% confidence interval [CI] 1.83-5.64) for the intermediate, 7.80 (95% CI 4.52-13.48) for the high, and 27.24 (95% CI 13.8-53.8) for the very high risk group (all p<0.001). These prognostic risk categories can be used to design postoperative follow-up schedules. A multidisciplinary approach can be considered for patients at high and very high risk of eGFR decline. PATIENT SUMMARY: We propose a new stratification system to identify individuals at high risk of a decline in renal function after robotic partial nephrectomy., (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: Robotic surgery has significantly advanced the minimally-invasive management of kidney tumors with extension into the inferior vena cava requiring caval cross-clamping and tumor thrombectomy. Additional techniques have recently been developed to continue the evolution of this complex procedure and extend its indications., Objective: To review the current state of the art as regards robotic nephrectomy with inferior vena cava thrombectomy (RNIT)., Evidence Acquisition: A systematic review of the Medline database was performed. All literature available through October 2016 was included., Evidence Synthesis: RNIT has been successfully adopted at select centers, but the number of patients reported to date remains limited. Modifications in clamping and tumor thrombus management have been described allowing for multiple options in surgical technique. Early perioperative outcomes appear favorable in comparison with traditional, open surgery, but further experience is needed., Conclusions: Feasibility and reproducibility of RNIT has been demonstrated, but longer-term outcomes and larger patient numbers are necessary before the role of this procedure is established., Patient Summary: Kidney cancers invading the largest vein in the body, the vena cava, require complex surgery for removal. Traditionally this has required a large incision, but newer techniques with robotic surgery that continue to evolve have allowed for a minimally-invasive approach., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)