Search

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

Background Despite efforts aimed at preserving renal function, the functional decline after robot-assisted partial nephrectomy (RAPN) is not negligible. To address the risk of intraparenchymal vessel injuries during renorrhaphy, with consequent loss of functional renal parenchyma, we introduced a new surgical technique for RAPN. Objective To compare perioperative patient outcomes between selective-suturing or sutureless RAPN (suRAPN) and standard RAPN (stRAPN). Design, setting, and participants Ninety-two consecutive patients undergoing RAPN for a renal mass performed by a high-volume surgeon at a European tertiary center were included. Propensity-score matching was used to account for baseline differences between suRAPN and stRAPN patients. Intervention RAPN using a selective-suturing or sutureless technique versus standard RAPN. Outcome measurements and statistical analysis Perioperative outcomes included operative time, blood loss, length of stay, and intraoperative and 30-d postoperative complications. We also evaluated trifecta achievement (warm ischemia time ≤25 min, negative surgical margins, and no perioperative complications) and the incidence of postoperative acute kidney injury (AKI). We applied χ2 tests, t tests, and Kruskal-Wallis tests to assess differences in perioperative outcomes between suRAPN and stRAPN. Results and limitations Overall, 29 patients (31%) were treated with suRAPN. Only one suRAPN patient experienced intraoperative complications (p = 0.9). Two suRAPN patients (6.9%) and four stRAPN patients (13.8%) experienced 30-d postoperative complications (p = 0.3). Operative time (110 vs 150 min; p Conclusions A selective-suturing or sutureless technique in RAPN is feasible and safe. Moreover, suRAPN is a lower-impact surgical procedure. We obtained promising results for trifecta and functional outcomes, but prospective randomized trials are needed to validate the impact of selective suturing or a sutureless technique on long-term functional outcomes. Patient summary We assessed a new technique in robotic surgery to remove part of the kidney because of kidney cancer. Our new technique involves selective suturing or no suturing of the area from where the tumor is removed. We found that the rate of complications did not increase and the operating time and length of hospital stay were shorter using this new technique.

To compare the feasibility and outcomes of renal mass biopsies (RMB) of anatomically complex vs non-complex renal masses.Our institutional renal tumor database was queried for patients who underwent RMB between 2005 and 2019 and with available nephrometry score. Complex masses were: (1) small (2 cm), (2) entirely endophytic (nephrometry E=3), (3) hilar (h) or (4) partially endophytic (E=2) and anterior. Demographic and pathologic data were compared. Biopsies were deemed adequate if they resulted in a diagnosis. Concordance with surgical pathology was assessed. These were both presented using proportions. Factors associated with biopsy outcomes were identified using multivariable logistic regression. RMB sensitivity and specificity were calculated using contingency methods.A total of 306 RBMs were included, 179 complex and 127 non-complex. A total of 199 (65%) had an extirpative procedure. Complex lesions were less likely to have an adequate biopsy (89% vs 96%, P = .03), and to be concordant with final surgical pathology from an oncologic standpoint (89% vs 97%, P = .03). There was no significant difference in concordance of histology (76% vs 86%, P = .10) or grade (48 vs 51%, P = .66). On multivariable analyses, only male gender was associated with biopsy adequacy (OR 3.31, 95% CI 1.28-8.55, P = .01). Our overall sensitivity was 93%, specificity 93%, and accuracy 93%. There were no significant differences over time in biopsy outcomes during the study period.RMB of complex lesions is associated with excellent diagnostic yield, albeit lower than non-complex lesions. RMB should not be deferred in cases of anatomically complex lesions where additional data could improve clinical decision-making.

Objective To evaluate MUSIC-KIDNEY's adherence to the American Urological Association (AUA) guidelines regarding the initial evaluation of patient's with clinical T1 (cT1) renal masses. Methods We reviewed MUSIC-KIDNEY registry data for patients with newly diagnosed cT1 renal masses to assess for adherence with the 2017 AUA guideline statements regarding recommendations to obtain (1) CMP, (2) CBC, (3) UA, (4) abdominal cross-sectional imaging, and (5) chest imaging. An evaluation consisting of all 5 guideline measures was considered “complete compliance.” Variation with guideline adherence was assessed by contributing practice, management strategy, and renal mass size. Results We identified 1808 patients with cT1 renal masses in the MUSIC-KIDNEY registry, of which 30% met the definition of complete compliance. Most patients received care that was compliant with recommendations to obtain laboratory testing with 1448 (80%), 1545 (85%), and 1472 (81%) patients obtaining a CMP, CBC, and UA respectively. Only 862 (48%) patients underwent chest imaging. Significant variation exists in complete guideline compliance for contributing practices, ranging from 0% to 45% as well as for patients which underwent immediate intervention compared with initial observation (37% vs 23%) and patients with cT1b masses compared with cT1a masses (36% vs 28%). Conclusion Complete guideline compliance in the initial evaluation of patients with cT1 renal masses is poor, which is mainly driven by omission of chest imaging. Significant variation in guideline adherence is seen across practices, as well as patients undergoing an intervention vs observation, and cT1a vs cT1b masses. There are ample quality improvement opportunities to increase adherence and decrease variability with guideline recommendations.

Patient with "very small" (2 cm) renal mass can be offered active surveillance, thermal ablation, or partial nephrectomy. The management strategy will consider patient preferences and prioritize potential harms associated with each of these options. To date, outcomes of robot-assisted partial nephrectomy (RAPN) in patients with "very small" renal masses have not been reported.To assess the outcomes of RAPN among patients with "very small" renal masses.This was a retrospective analysis of a multi-institutional database including RAPN cases performed at eight high-volume US and European centers between 2009 and 2019. Patients were stratified into two groups according to clinical tumor size:2 cm ("very small" renal mass, study group) and 2-4 cm (control group).RAPN for renal masses.Baseline characteristics and intraoperative, pathological, and postoperative data were compared between the study and the control group. A "trifecta" was used as surrogate of "surgical quality."Overall, a total of 1019 patients were included in the analysis. Of these, 352 had a renal mass of2 cm (34.5%) and 667 (65.5%) had a renal mass of 2-4 cm. At baseline, the study group presented a lower rate of chronic kidney disease ≥stage III (p0.001), a lower RENAL score (p = 0.001), and lower rates of hilar (p = 0.04) and endophytic (p = 0.02) masses. Warm ischemia time was shorter for the study group (median 14 vs 18 min, p0.001), which also showed a lower rate of overall postoperative complications (9.6% vs 14.7%, p0.001) and no major complications. In terms of oncological outcomes, three and ten patients developed a local recurrence in the study and the control group, respectively (p = 0.1). In the study group, higher estimated glomerular filtration rates were found at discharge (p = 0.001) and at the last follow-up (p = 0.007), which showed a "trifecta" achievement of 90.6%. The retrospective design may limit the generalizability of the findings.Whenever an active treatment is indicated or warranted, RAPN represents a minimally invasive management option for "very small" renal masses, as it carries minimal risk of complications and has minimal impact on renal function. While both active surveillance and kidney ablation remain valid management options in these cases, RAPN can be offered and discussed with patients as it provides excellent outcomes with low morbidity.In this report, we observed that robot-assisted partial nephrectomy represents a true minimally invasive active treatment for "very small" renal masses (2 cm), as it carries minimal risk of complications and has minimal impact on renal function.

Mucinous tubular and spindle cell carcinoma (MTSCC) is a rare renal malignancy that usually follows an indolent course. The few existing reports of metastatic MTSCC show poor response to systemic therapy. Here we describe the unusual case of a 39-yr-old male with MTSCC presenting as a large renal mass with bulky retroperitoneal lymphadenopathy managed with complete resection of disease. He has remained free of recurrence for 1 yr postoperatively. On the basis of the experience reported here, aggressive surgical resection of MTSCC with isolated nodal metastases may be considered for similar patients in the future given the historically poor response rates to systemic therapy.

Renal masses are commonly encountered on cross-sectional imaging examinations performed for nonrenal indications. Although most can be dismissed as benign cysts, a subset will be either indeterminate or suspicious; in many cases, imaging cannot be used to reliably differentiate between benign and malignant masses. On-going research in defining characteristics of common renal masses on advanced imaging shows promise in offering solutions to this issue. A recent update of the Bosniak classification (used to categorize cystic renal masses) was proposed with the goals of decreasing imaging follow-up in likely benign cystic masses, and therefore avoiding unnecessary surgical resection of such masses.

In the 2016 World Health Organization renal tumor classification, the mixed epithelial and stromal tumor family was introduced as a new entity. This family encompasses a spectrum of tumors, ranging from predominantly cystic tumors (adult cystic nephromas) to tumors that are variably solid (mixed epithelial and stromal tumors). The majority of previous studies incorporating “mixed epithelial and stromal tumor” in the titles were actually reports of imaging findings of adult cystic nephroma. Thus, the solid component of mixed epithelial and stromal tumors has not been well evaluated. In this study, we present 2 cases of mixed epithelial and stromal tumors, as defined by the 2016 World Health Organization classification, showing a predominantly solid component. The characteristic findings of the solid component of these tumors were T2-hypointensity on magnetic resonance imaging and hyperattenuation on unenhanced computed tomography. Angiomyolipoma with epithelial cysts and epithelioid angiomyolipoma should be considered in the differential diagnosis of mixed epithelial and stromal tumors.

Introduction The purpose of this study was to evaluate the impact of 3-dimensional (3D) digital reconstructions of renal models on the arterial clamping approach during partial nephrectomy (PN). Patients and Methods Fifty-seven patients with T1 renal mass, referred for PN, were prospectively enrolled in 2 groups: Group 1 (n = 32) with revision of both 2-dimensional (2D) computed tomography (CT) imaging and 3D virtual model before surgery; Group 2 (n = 25) with revision of 2D CT imaging. Segmentation of the 3D models from preoperative high-quality CT scan was achieved using D2P software. In a sub-analysis of patients treated with PN with the on-clamp approach (n = 36), the effective intraoperative level of arterial clamping was compared with the preoperative planning. Results In the sub-group of patients referred to PN with the on-clamp approach, the intraoperative selective clamping was performed in 12 (57.1%) patients of Group 1 and in 2 (13.3%) cases of Group 2 (P = .01). The intraoperative management of the renal pedicle was done as preoperatively planned in 61.9% of patients in Group 1 and in 86.6% of cases in Group 2 (P = .1). Conclusion The 3D-guided plan of PN allows to perform selective clamping in higher proportion of patients compared with the standard 2D-guided approach without increasing intraoperative and postoperative complications.

DICER1 syndrome is a rare hereditary cancer predisposition syndrome that has relevance to pediatric urology providers due to its association with many various pediatric genitourinary malignancies. We describe the case of a pediatric patient who was eventually diagnosed with a pathogenic DICER1 germline variant after undergoing resection of a cystic nephroma and pleuropulmonary blastoma.

Patients with a renal mass traditionally proceed directly to surgery without a preoperative tissue diagnosis confirming malignancy. Many surgically treated renal masses represent benign tumors or indolent malignancies on final pathology. This has led to a growing body of literature supporting an expanded role for percutaneous renal mass biopsy (RMB). This study aims to characterize national trends in RMB utilization.Patients undergoing renal biopsy during a 12-year period (2006-2017) in the Premier Hospital Database were captured using International Classification of Diseases, Ninth Revision and Tenth Revision codes. We restricted our analysis to patients with a concurrent diagnosis of a renal mass. We determined utilization rate, subsequent interventions within 90 days of biopsy, predictors of RMB, and 30-day RMB complication rates. We applied sampling weights and adjusted for hospital clustering to achieve a nationally representative analysis.Among 115,511 patients who met the inclusion criteria, the annual number of RMB rose from 7,196 in 2006 to 11,528 in 2017; during this period, more than 3 times as many patients proceeded directly to surgery without a prior RMB. After RMB, 85,848 (74.32%) patients were not treated within 90 days. Of those treated, thermal ablation was more common than surgery (17,269 vs. 12,394). Trend analysis showed that patients with metastatic disease represented a decreasing proportion of patients receiving RMB (27.0%-21.8%; P0.001). Compared to patients who proceeded directly to surgery, RMB was more commonly performed in patients in the highest age group (80 years and older, 15.9% vs. 9.2%), unmarried (50% vs. 45.9%), with more medical comorbidities (Charlson comorbidity index ≥4, 30.9% vs. 17.4%), or with metastatic disease (24.5% vs. 10.4%). Multivariable regression analysis determined the primary predictor of RMB was the presence of metastatic disease. Hematuria was the most common complication present in 5.18% of patients followed by pneumothorax in 1.75%. All other complications were rare (0.4%).Although there has been progressive adoption of RMB for the management of renal masses in the United States, utilization remains relatively limited and differentially employed across the population based on both clinical and nonclinical patient factors. More research is needed to understand which factors are considered when determining whether to utilize RMB in the evaluation of a renal mass.

Objective To describe a novel approach for reconstructing the superior mesenteric artery (SMA) during left nephrectomy and review the literature. Materials and Methods The patient was a 57-year-old man with left back pain from an unknown cause for more than 3 hours. A computed tomography scan showed a 12- × 15-cm firm mass and a subcapsular hematoma in the left kidney. It was considered to be bleeding and rupture of the solid renal mass, and because of persistent pain and no documented distant metastatic disease, a transperitoneal laparoscopic nephrectomy was elected, but the procedure was converted to open surgery for SMA injury. We reconstructed the SMA with end-to-end anastomosis between the SMA and the left renal artery stump. Results At the 6-year follow-up, the patient had no intestine-related sequelae. Conclusion Our novel approach of an end-to-end anastomosis between the SMA and the left renal artery stump is an option for SMA injury, especially when orthotopic anastomosis or repair of the SMA is not indicated.

Radiomics allows for high throughput extraction of quantitative data from images. This is an area of active research as groups try to capture and quantify imaging parameters and convert these into descriptive phenotypes of organs or tumors. Texture analysis is one radiomics tool that extracts information about heterogeneity within a given region of interest. This is used with or without associated machine learning classifiers or a deep learning approach is applied to similar types of data. These tools have shown utility in characterizing renal masses, renal cell carcinoma, and assessing response to targeted therapeutic agents in metastatic renal cell carcinoma.

Renal masses increasingly are found incidentally, largely due to the frequent use of medical imaging. Computed tomography (CT) and MR imaging are mainstays for renal mass characterization, presurgical planning of renal tumors, and surveillance after surgery or systemic therapy for advanced renal cell carcinomas. CT protocols should be tailored to different clinical indications, balancing diagnostic accuracy and radiation exposure. MR imaging protocols should take advantage of the improved soft tissue contrast for renal tumor diagnosis and staging. Optimized imaging protocols enable analysis of imaging features that help narrow the differential diagnoses and guide management in patients with renal masses.

Multiparametric MR provides a noninvasive means for improved differentiation between benign and malignant solid renal masses. Although most large, heterogeneous renal masses are due to renal cell carcinoma, smaller "indeterminate" renal masses are being identified on cross-sectional imaging. Although definitive diagnosis of a solid renal mass may not always be possible by MR imaging, integrated evaluation of multiple MR imaging parameters can result in concise differential diagnosis. Multiparametric MR should be considered a critical step in the triage of patients with a solid renal mass for whom treatment options are being considered in the context of morbidity, prognosis, and mortality.

In clinical practice, objective basis for the choice between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) is scarce. To evaluate surgical outcomes, assess the individual benefit from LPN to RAPN, which can guide clinical decision-making.Patients underwent LPN or RAPN for a localized renal mass in our center between Jan 2013 and Dec 2016 were included. The surgical outcome of LPN and RAPN was the pentafecta achievement. A multivariable model was fitted to predict the probability of pentafecta achievement after LPN. Model-derived coefficients were applied to calculate the probability of pentafecta achievement in case of LPN among patients treated with RAPN. Locally weighted scatterplot smoothing method was applied to plot the observed probability of pentafecta achievement against the predicted pentafecta probability in case of LPN.RAPN group had a significantly higher pentafecta achievement (54.6% vs. 41.1%, P 0.001) than LPN. Multivariable analyses identified that tumor size, distance of the tumor to collecting system or sinus, and preoperative eGFR were independent predictors of pentafecta after LPN. When RAPN was chosen over LPN, the increase in the probability of pentafecta achievement was greatest in intermediate-probability patients. With the increase or decrease of the probability of pentafecta, the benefit of RAPN decreased.When pentafecta achievement are assessed, the benefit of RAPN over LPN varies from patient to patient. Patients at intermediate-probability of pentafecta achievement after LPN benefit the most from robotic surgery, which may be the potential ideal candidates for RAPN.

Case Presentation A 29-year-old Ukrainian woman presented to the obstetric clinic at 28 weeks’ gestation with pregnancy complicated by intrauterine growth restriction. She reported progressively worsening dyspnea during her pregnancy and was found to have significant hypoxia with an oxygen saturation of 84% on room air prompting admission for further evaluation. Oxygen saturation improved to 92% on 10 L of supplemental oxygen. On further questioning, she was found to have a history significant for pleurodesis as a treatment for recurrent pneumothoraces and nephrectomy for a benign renal mass several years prior while living in Ukraine.

One of the consequences of the growing use of diagnostic imaging techniques is the notable growth in the detection of small renal masses presumably corresponding to localized tumors that are potentially curable with surgical treatment. When faced with the finding of a small renal mass, radiologists must determine whether it is benign or malignant, and if it is malignant, what subtype it belong to, and whether it should be managed with surgical treatment, with ablative techniques, or with watchful waiting with active surveillance. Small renal masses are now a clinical entity that require management different from the approaches used for classical renal cell carcinomas. In this scenario, radiologists are key because they are involved in all aspects of the management of these tumors, including in their diagnosis, treatment, and follow-up.

Highlights • Renal angiomyolipoma is a benign Tumor, composed of adipose tissue, smooth muscle tissue and blood vessels. • Epithelioid angiomyolipoma (EAML), is a rare variant of angiomyolipoma with malignant potential. • There are less than 10 cases reported as huge (larger than 10 cm) epithelioid angiomyolipoma in the English literature, all associated with recurrence and complications. • We reported a case of benign giant epithelioid angimyolipoma without association to Tuberous Sclerosis. • The patient was a benign case treated via surgical resection and no concurrent treatment was required to achieve great outcome., Introduction Renal angiomyolipoma (also called renal hamartoma) is a benign Tumor, composed of adipose tissue, smooth muscle tissue, and blood vessels. Tumors more than 10 cm (referred to as “giant” AMLs) are infrequent and a very small number of reported cases were measured more than 20 cm. Epithelioid angiomyolipoma (EAML), is a rare variant of angiomyolipoma with malignant potential. There are less than 10 cases of huge EAML reported in English literature, that were all associated with recurrence and complications. Case presentation Here we report a rare case of renal EAML in a 48-year-old male patient that was not associated with tuberous sclerosis. He was admitted to our hospital with a complaint of severe abdominal pain. Computer Tomography Scan (CT-scan), revealed two masses attached to the left kidney with a size of 32 × 22 × 8 cm and 20 × 10 × 3 cm. The patient underwent a radical left nephrectomy. Postoperative histopathological examination confirmed the diagnosis of an EAML. The two-year follow-up CT-scan showed no recurrence. Conclusion Malignant EAML, although rare, does exist. Thus, besides evaluations required for ruling out the diagnosis of renal sarcomas, surgeons must follow patients after total nephrectomy for possible recurrence. Benign cases can be completely cured by surgery and do not show recurrence at the end of the follow-up period.

The incidence of renal tumor on the allograft kidney is relatively rare. There is no standard treatment available for the management of such cases. However, if technically feasible nephron-sparing surgical approaches, whether open or minimally invasive, should be preferred for the management of these challenging cases. To our knowledge, there is no pure laparoscopic technique reported in the literature but only 3 cases of robot-assisted partial nephrectomy. In this article, we aimed to present the application of pure transperitoneal laparoscopic partial nephrectomy for the management of a renal mass on the allograft kidney.

CONTEXT: Small renal masses (SRMs; tumors

Background Complexity of robot-assisted partial nephrectomy (RAPN) mostly depends on tumor size and location. Totally endophytic renal masses represent a surgical challenge in terms of both intraoperative identification and anatomical dissection. Objective To detail a novel technique for marking preoperatively endophytic renal tumors with transarterial superselective intrarenal mass delivery of indocyanine green (ICG)-lipiodol mixture, in order to enhance surgical margins control during purely off-clamp (OC) RAPN with the use of near-infrared fluorescence imaging. Design, setting, and participants Between June and July 2017, 10 consecutive patients with totally endophytic renal masses underwent preoperative ICG tumor marking immediately followed by RAPN. Surgical procedure Preoperative superselective transarterial delivery of a lipiodol-ICG mixture (1:2 volume ratio) into tertiary-order arterial branches feeding the renal mass prior to transperitoneal OC-RAPN. Measurements Clinical data were prospectively collected in our institutional RAPN dataset. Perioperative, pathological, and functional outcomes of RAPN were assessed. Results and limitations Median tumor size was 3cm (interquartile range 2.3–3.8). The median PADUA score was 10 (9–11). Angiographic procedure was successful in all patients. Median operative time was 75min (65–85); median estimated blood loss was 250ml (200–350). No conversion to on-clamp PN or radical nephrectomy was needed. All patients had uneventful perioperative course; median hospital stay was 3 d (2–3). At discharge, median hemoglobin (Hgb) and percent estimated glomerular filtration rate (eGFR) drop were 3.3g/dl (2.1–3.3) and 11% (10–20%), respectively. Surgical margins were negative in all cases. One-year median ipsilateral renal volume and 1-yr eGFR percent decreases were 11.7% (6–20.9%) and 12.2% (5.3–13.7%), respectively. Conclusions We described a novel technique to simplify challenging RAPN based on ICG superselective transarterial tumor marking. Key benefits include quick intraoperative identification of the mass with improved visualization and real-time control of resection margins. Patient summary Robot-assisted partial nephrectomy (RAPN) for totally endophytic renal masses is a technically demanding surgical procedure, sometimes requiring radical nephrectomy. This novel technique significantly simplified surgical complexity in our Institution. Further studies with larger cohorts are warranted to confirm whether this technique provides relevant intraoperative and functional advantages.

Summary Purpose We describe a rare case of anatomical variation of the collaterals of the abdominal aorta associated with a duplication of the pyelic. Material and method A 51-year-old patient in whom an abdominal CT scan was performed as part of the exploration of a cystic left renal mass objectified on ultrasound. Results A celiomesenteric trunk with two left renal arteries and a duplication of the left pyelon were found. Conclusion The reported case is of interest in the rare association of these anatomical variants.

Robot-assisted partial nephrectomy (RAPN) outcomes might be importantly affected by increasing surgical experience (EXP). The aim of the study is to investigate the effect of EXP on warm ischemia time (WIT), presence of at least one Clavien-Dindo ≥2 postoperative complication (CD ≥ 2), and positive surgical margins (PSMs) to define the learning curve for RAPN. We evaluated 457 consecutive patients diagnosed with a cT1-T2 renal mass were evaluated. EXP was defined as the total number of RAPNs performed by each surgeon before each patient's operation. Median WIT was 14min and the rate of CD ≥ 2 and PSMs was 15% and 4%, respectively. At multivariable regression analyses adjusted for case mix, EXP resulted associated with shorter WIT (p

International guidelines suggest the use of anatomic scores to predict surgical outcomes after partial nephrectomy (PN). We aimed at validating the use of Simplified PADUA Renal (SPARE) nephrometry score in robot-assisted PN (RAPN).Three hundred and sixty-eight consecutive RAPN patients were included. Primary endpoints were overall complications, postoperative acute kidney injury (AKI) and TRIFECTA achievement. Secondary endpoint was estimated glomerular filtration rate (eGFR) decrease at last follow-up. Multivariable logistic and linear regression models were used.Of 368 patients, 229 (62%) vs. 116 (31%) vs. 23 (6.2%) harboured low- vs. intermediate- vs. high-risk renal mass, according to SPARE classification. SPARE score predicted higher risk of overall complications (Odds ratio [OR]: 1.23, 95%CI 1.09-1.39; P0.001), and postoperative AKI (OR: 1.20, 95%CI 1.08-1.35; P0.01). Moreover, SPARE score was associated with lower TRIFECTA achievement (OR: 0.89, 95%CI 0.81-0.98; P = 0.02). Predicted accuracy was 0.643, 0.614 and 0.613, respectively. After a median follow-up of 40 (IQR: 21-66) months, eGFR decrease ranged from -7% in low-risk to -17% in high-risk SPARE.SPARE scoring system predicts surgical success in RAPN patients. Moreover, SPARE score is associated with eGFR decrease at long-term follow-up. Thus, the adoption of SPARE score to objectively assess tumor complexity prior to RAPN may be preferable.

Since its clinical inception a decade ago, dual-energy computed tomography has expanded the array of computed tomography imaging tools available to the practicing abdominal radiologist. Of note, diagnostic solutions for imaging-based evaluation of genitourinary diseases, foremost kidney calculi and renal tumors characterization, represent the apogee applications of dual-energy computed tomography in abdominal imaging. This article reviews clinical applications of dual-energy computed tomography for the assessment of genitourinary diseases.

Spinal schwannomas arise from the cells covering the nerves within the spinal canal. In most cases, they remain confined within the intradural extramedullary space, but occasionally they extend into the extradural space resembling abdominal masses.We present a case of very large spinal schwannoma mimicking a renal mass at ultrasound exam. Using contrast-enhanced computed tomography and magnetic resonance imaging we were able to detect and characterize the lesion and consequently assign a preoperative diagnosis later confirmed by the histopathology report.In this paper, we review computed tomography and magnetic resonance imaging features of spinal schwannomas and attempt a summary of possible differential diagnoses. Keywords: Spinal schwannomas, Spinal tumors, MRI, Neuroradiology

Image-guided renal biopsies have an increasing role in clinical practice. Renal mass and renal parenchymal biopsy indications, techniques, and other clinical considerations are reviewed in this article. Image-guided renal mass ablation shows significant promise and increasing clinical usefulness as more studies demonstrate its safety and efficacy. Renal mass ablation indications, techniques, and other considerations are also reviewed.

Purpose To determine if the use of heat-based track ablation with new-generation cryoprobes is associated with decreased renal cryoablation bleeding complications. Materials and Methods Eighty-nine patients who underwent percutaneous cryoablation for treatment of a solitary renal mass with the use of cryoprobes with track ablation (CwTA) from October 29, 2015, to May 18, 2017, were compared with a propensity score–matched control group of 178 patients who underwent treatment with the use of cryoprobes without track ablation (Cw/oTA) from January 5, 2012, to October 28, 2015. Bleeding complications were assessed with the use of the Clavien-Dindo classification system and compared between the matched patient groups by means of conditional logistic regression, both univariately and in a multivariate model to adjust for imbalanced covariates. Change in patient hemoglobin was evaluated as a secondary measure of periprocedural bleeding. Results Seven of the 89 patients (7.9%) who underwent percutaneous renal cryoablation with the use of CwTA developed major (grade ≥3) bleeding complications, versus 13 of the 178 patients (7.3%) treated with the use of Cw/oTA. Conditional logistic regression analysis adjusted for potential confounders showed that major, minor, and overall bleeding complications were not associated with the type of cryoprobes used for treatment ( P values .727, .370, and .733, respectively). There was also no significant difference in postprocedural change in hemoglobin for patients treated with the use of CwTA compared with Cw/oTA ( P = .909). Furthermore, total duration of track ablation in patients with bleeding complications (mean 169 seconds, SD 68, range 60–240) was not significantly different than in patients without bleeding complications (mean 171 seconds, SD 86, range 30–360; P = .940). Conclusions The use of cryoprobes with heat-based track ablation did not decrease the incidence of bleeding complications after renal cryoablation compared with procedures performed without track ablation.

Opponents of premanagement biopsy of small renal masses are not difficult to find. Many urologists contend that the benefits of biopsy do not outweigh the risks, arguing that the results do not influence management substantially and that the most useful information from renal mass biopsy can be attained with advanced imaging. In this article, we develop the counter arguments and demonstrate that renal mass biopsy should be implemented into the small renal mass management algorithm.

Kidney cancer accounts for 2% of cancer related deaths. Historically, a patient with a solid renal mass would undergo surgery without biopsy given the previously low diagnostic yield of biopsy and the fear of tumor seeding. This led to a high rate of resection for benign masses. With the rising incidence of renal masses discovered on imaging, improvements in biopsy technique and advancements in pathologic evaluation of biopsy samples of renal masses, renal mass biopsy now plays an important role in selected patients with renal masses. Coaxial core needle biopsy is the preferred technique with a low rate of complications and a high diagnostic yield. This article will discuss indications, methods, utility, limitations and complications of renal mass biopsy.

Upper Tract Urothelial Carcinomas (UTUC) are generally uncommon, accounting for approximately 5% of all urinary tract tumours. This report describes a unique Case of a 52-year-old-male with no known risk factors or symptoms of UTUC, who presented with bilateral sub-massive pulmonary embolus (PE). Subsequent computed tomography (CT) demonstrated a small (

Introduction and objectives Renal mass biopsy (RMB) has not been widely adopted in evaluating small renal mass due to concerns for safety, efficacy, and its perceived lack of consequence on management decisions. We assess the potential cost savings and morbidity avoidance of routine RMB on cT1 renal masses undergoing robotic-assisted partial nephrectomy (RAPN). Methods We identified n = 920 consecutive RAPN pT1 renal masses and n = 429 consecutive RMBs for cT1 renal masses over 12 years. Using a novel pathological-based risk classification system for cT1 renal masses, we evaluated the morbidity and costs of our RAPN and RMB cohorts. We then define four clinical scenarios where RMB could potentially delay and/or avoid intervention in our pT1 RAPN cohort and model potential complications prevented and cost savings utilizing common clinical scenarios. Results Using our risk stratification system in RAPN patients, final histology was classified as benign in n=174 (18.9%) cases, very low-risk (n = 62 [7%]), low-risk (n = 383 [42%]), and high-risk (n = 301 [33%]), respectively. We identified n = 116 (12.6%) Clavien graded peri-operative complications. In our RMB patients, 120 (27.9%), 17 (3.9%), 240 (55.9%), 52(12.1%) were benign, very low, low and high-risk tumors. The median total direct cost for RAPN was $6955/case compared to $1312/case for RMB. If we established a primary goal to avoid immediate extirpative surgery in benign renal tumors, in the elderly (>70 y) with very low-risk tumors and/or those with high renal functional risks (≥ CKD3b), or competing risks (ASA ≥ 3), RMB could have reduced direct costs by approximately 20% and avoided n = 39 Clavien graded complications, seven readmissions, three transfusions, and two returns to the OR. With the additional cost of performing RMB on those not initially biopsied, the net cost saving would be approximately $1.2 million with minimal added complications while still treating high-risk tumors. Conclusions Routine RMB before intervention results in cost-saving and complication avoidance. Given the limitations of biopsy, shared decision-making is mandatory. Biopsy should be considered prior to intervention in at-risk populations.

Autosomal dominant polycystic kidney disease (ADPKD) is most common potentially lethal cystic occurring in approximately 1 in 1000 live births. It is an important cause of end stage renal disease which occurs in 75% of patients by the age of 70 years. ADPKD is a systematic disease with involvement of multiple extra renal organs. Incidence of renal cell cancer in ADPKD is no more than in normal population. High index of suspicion is required due to gross distortion of renal architecture. Nephron sparing surgery should be offered if feasible as patients are prone to chronic renal failure. Laparoscopic approach is technically challenging in view of adjacent multiple renal cyst. We report a case of renal mass in ADPKD managed with a laparoscopic nephron sparing approach.

The wide availability of cross-sectional imaging is responsible for the increased detection of small, usually asymptomatic renal masses. More than 50 % of renal cell carcinomas (RCCs) represent incidental findings on noninvasive imaging. Multimodality imaging, including conventional US, contrast-enhanced US (CEUS), CT and multiparametric MRI (mpMRI) is pivotal in diagnosing and characterizing a renal mass, but also provides information regarding its prognosis, therapeutic management, and follow-up. In this review, imaging data for renal masses that urologists need for accurate treatment planning will be discussed. The role of US, CEUS, CT and mpMRI in the detection and characterization of renal masses, RCC staging and follow-up of surgically treated or untreated localized RCC will be presented. The role of percutaneous image-guided ablation in the management of RCC will be also reviewed.

Gestational choriocarcinoma is an uncommon trophoblastic malignancy, occurring in females after pregnancy, which is rarely encountered by urologists. It can be rapidly progressive, however metastases to other organs can occur after a prolonged latency period. We describe a rare case of solitary metastatic gestational choriocarcinoma presenting with spontaneous bleeding from a renal mass, over a decade after the associated pregnancy with a presumed sub-clinical primary tumour. This case demonstrates the importance of recognising gestational choriocarcinoma as a potential differential diagnosis of spontaneous bleeding renal mass in females of child-bearing age as a urologist given the often-aggressive nature of the disease.

Background Renal mass biopsy (RMB) is a safe and accurate method for diagnosis and clinical management of renal masses. However, the non-diagnostic rate is a limiting factor. We tested the hypothesis that imaging characteristics and anatomic complexity of the mass may impact RMB diagnostic outcome using the preoperative aspects and dimensions used for an anatomical (PADUA) classification and radius-exophytic/endophytic-nearness-anterior/posterior-location (RENAL) score. Material and methods Single institution, retrospective study of 490 renal masses from 443 patients collected from 2001 to 2018. Outcome measurements include (1) diagnostic and concordance rates amongst RMB types and RMB with surgical resection specimens; (2) association between diagnostic RMB and anatomical complexity of renal masses. The analysis was conducted in unselected masses and small renal masses (SRMs). Results RMB was performed by fine needle aspiration (FNA), core needle biopsy (CNB), or both (FNA+CNB). Non-diagnostic rate was significantly higher for FNA compared to CNB and FNA+CNB in both unselected and SRMs. Subset analysis in the FNA+CNB group showed similar diagnostic rates for FNA and CNB. In unselected masses, specificity for FNA, CNB, and FNA+CNB was 100%. Sensitivity was higher for CNB (90.1%, P = 0.002) and FNA+CNB (96.3%, P = 0.004) compared to FNA (66.7%). For unselected masses, endophytic growth predicted a non-diagnostic CNB. R.E.N.A.L location entirely between the polar lines (central) and entirely above the upper polar line predicted a diagnostic CNB. Sonography-guidance predicted a diagnostic FNA. For SRMs, non-diagnostic CNB was associated with endophytic growth, while diagnostic CNB was associated with renal sinus invasion and operator experience. More cystic masses were sampled by FNA, but diagnostic results were similar for FNA and CNB. Conclusions Endophytic growth consistently predicted a non-diagnostic CNB in unselected and SRMs, whereas sonography-guidance predicted a diagnostic FNA. Cystic masses could be adequately sampled by FNA.

Active surveillance for small renal masses (SRMs) is an accepted management strategy for patients with prohibitive surgical risk. Emerging prospectively collected data support the concept that a period of initial active surveillance in an adherent patient population with well-defined criteria for delayed intervention is safe. This article summarizes the literature describing growth kinetics of SRMs managed initially with observation and oncologic outcomes for patients managed with active surveillance. Existing clinical tools to determine and contextualize competing risks to mortality are explored. Finally, current prospective clinical trials with defined eligibility criteria, surveillance schema, and triggers for delayed intervention are highlighted.

The coexistence of different bone diseases in the same patient involves a complex differential diagnosis. A patient is presented who was studied due to a renal mass that showed many sclerotic lesions in spine and limbs in conventional radiology and CT. These lesions were evaluated with 99mTC-HDP bone scintigraphy and 18F-FDG PET/CT, which helped to obtain the definitive pathological diagnosis of osteopoikilosis (OP) co-existing with gastric cancer bone metastases. Of the different imaging scans performed, bone scintigraphy was particularly relevant due to its ability to discriminate between benign and metastatic bone disease.

Most small renal masses (SRMs) are indolent. In fact, only approximately 80% of SRMs are malignant. Furthermore, SRMs are commonly detected in elderly and comorbid patients. Therefore, opportunities for better care intensity calibration exist. Renal mass biopsy (RMB), when appropriately used, is a valuable clinical tool to help with critical clinical decision-making in patients with SRM. This article summarizes the role of modern RMB in helping gauge care for patients with SRM.

Anatomic tumor complexity can be objectively measured and reported using nephrometry. Various scoring systems have been developed in an attempt to correlate tumor complexity with intraoperative and postoperative outcomes. Nephrometry may also predict tumor biology in a noninvasive, reproducible manner. Other scoring systems can help predict surgical complexity and the likelihood of complications, independent of tumor characteristics. The accumulated data in this new field provide provocative evidence that objectifying anatomic complexity can consolidate reporting mechanisms and improve metrics of comparisons. Further prospective validation is needed to understand the full descriptive and predictive ability of the various nephrometry scores.