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Background: There is a lack of published data on real-world cabozantinib use in patients with advanced renal cell carcinoma after prior vascular endothelial growth factor (VEGF)-targeted therapy., Methods: CASSIOPE was a real-world, prospective, multicenter, non-interventional postauthorization safety study of cabozantinib in adult patients with advanced renal cell carcinoma in Europe following prior VEGF-targeted treatment (NCT03419572). Endpoints included cabozantinib utilization (dose modifications due to adverse events [AEs; primary endpoint], dose, dose modifications, and treatment duration), safety, effectiveness (progression-free survival [PFS], overall survival [OS], best overall response [BOR]), and healthcare resource utilization., Findings: Full analysis set (FAS)/safety population comprised 679 patients; 433 of these initiated cabozantinib at 60 mg/day (recommended dose) (primary safety population). Median age (FAS) was 67 (range, 29-93) years; most were male (73·0%), had clear-cell histology (85·7%), metastatic disease at cabozantinib initiation (97·8%), and prior nephrectomy (80·3%). In the primary safety population, 77·1% experienced dose modification owing to an AE. In the safety population, the median daily dose was 40·0 (range, 7·8-60·0) mg/day and the median treatment duration was 7·8 (< 0·1-15·2) months. Treatment-emergent and treatment-related AEs were experienced by 95·9% and 90·4% of patients, respectively. Median PFS (FAS) assessed by the local investigator using any method was 8·3 months, and 1-year OS rate was 74%. Approximately one-third of all patients had a BOR of partial response and 6 had a complete response., Interpretation: Second- or later-line cabozantinib was effective and manageable in a real-world setting and had a safety profile consistent with previous studies., Competing Interests: Disclosure MS: Consulting or advisory role—Apogepha, Bristol-Myers Squibb, Eisai, EMD Serono, EUSA Pharma, Exelixis, Ipsen, Merck Sharp & Dohme, Novartis, Oncorena, Pfizer; Speakers’ bureau—Bristol-Myers Squibb, Eisai, EUSA Pharma, Ipsen, Novartis, Pfizer; Travel, accommodations, expenses—Bristol-Myers Squibb, Eisai, EMD Serono, EUSA Pharma, Ipsen, MSD Oncology, Novartis, Pfizer; Honoraria—Astellas Pharma, Bayer, Bristol-Myers Squibb, Incyte, EMD Serono, EUSA Pharma, Exelixis, Ipsen, MDS Oncology, Novartis, Pfizer, Roche; Research funding—Bayer, Bristol-Myers Squibb, Eisai, Exelixis, Novartis, Pfizer, Roche/Genentech. UB: Consulting or advisory role—AAA Novartis, AstraZeneca, Bristol-Myers Squibb, Pfizer; Research funding—Ipsen; Travel, accommodations, expenses—Astellas Pharma, Bayer, Bristol-Myers Squibb, Janssen Oncology, Ipsen, Merck/Pfizer, MSD Oncology; Other relationship—Astellas Pharma, AstraZeneca, Bayer, Bristol-Myers Squibb, Janssen Oncology, Ipsen, Merck/Pfizer, MSD. J-CE: Honoraria—Bristol-Myers Squibb, Ipsen, Pfizer; Consulting or advisory role—Bayer, Pfizer; Travel, accommodations, expenses—Janssen, Pfizer. PhB: Consulting or advisory role—AAA/Endocyte/Novartis, Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb, Eisai, Gilead Sciences, Ipsen, Janssen-Cilag, Merck KGaA, MSD Oncology, Pfizer; Travel, accommodations, expenses—Bristol-Myers Squibb, Ipsen, Janssen-Cilag, Merck/Pfizer, MSD, Pfizer; Honoraria—Astellas Pharma, Bayer, Bristol-Myers Squibb, Gilead Sciences, Ipsen, Janssen-Cilag, Merck KGaA, MSD, Novartis, Pfizer, Seattle Genetics. PiB: Honoraria—MSD; Consultancy or advisory role—Bristol-Myers Squibb, Ipsen, MSD. ML: Consulting or advisory role—Amgen, AstraZeneca, Bristol-Myers Squibb, Ipsen, MSD, Novartis, Pfizer; Speakers’ bureau—AstraZeneca, Ipsen; Travel, accommodations, expenses—Ipsen, MSD, Pfizer. MR: Consulting or advisory role—AstraZeneca, Bayer Healthcare, Bristol-Myers Squibb, Ipsen Pharma, MSD, Novartis, Pfizer, Roche; Honoraria—AstraZeneca, Bayer Healthcare, Bristol-Myers Squibb, Ipsen Pharma, MSD, Novartis, Pfizer, Roche; Speakers’ bureau—Bayer Healthcare, Bristol-Myers Squibb, EUSA Pharma, Ipsen Pharma, Novartis, Olympus, Pfizer, Roche. CS: Consulting or advisory role—Astellas Pharma, Bristol-Myers Squibb, Eisai, EUSA Pharma, Ipsen, Merck Sharp & Dohme, Pfizer, Roche/Genentech; Speakers’ bureau—Bristol-Myers Squibb, Eisai, Ipsen, Merck Sharp & Dohme, Pfizer, Roche/Genentech; Travel, accommodations, expenses—Bristol-Myers Squibb, Ipsen, Roche; Research funding—AB Science, Aragon Pharmaceuticals, Astellas Pharma, AstraZeneca, Bayer, Blueprint Medicines, Boehringer Ingelheim, Bristol-Myers Squibb, Clovis Oncology, Exelixis, GlaxoSmithKline, Novartis, Pfizer, Roche/Genentech, Sanofi Aventis GMbH. AG: Nothing to disclose. JB: Consulting or advisory role—Apogepha, Astellas, AstraZeneca, BMS, Eisai, Ipsen, Janssen, Merck Serono, MSD, Pfizer, Roche; Speakers’ bureau—Astellas, BMS, Ipsen, Merck Serono, MSD, Pfizer, Roche, Seagen; Research funding—Astellas, AstraZeneca, BMS, Eisai, Ipsen, MSD, Nektar, Novartis, Pfizer, Roche, Seagen; Travel, accommodations, expenses—Merck. PH: Consulting or advisory role—Astellas Pharma, AstraZeneca, Bristol-Myers Squibb, Ipsen, MDS, Pfizer. RDV: Honoraria—AstraZeneca, Bayer, Ipsen, Janssen, MDS, Pfizer; Travel, accommodations, expenses—AAA Novartis. PG: Consulting or advisory role—Astellas, Bristol-Myers Squibb, Ipsen, Merck, MSD, Pfizer, Roche; Speakers’ bureau—Astellas, Bristol-Myers Squibb, Ipsen, Merck, MSD, Pfizer, Roche; Travel, accommodations, expenses—Ipsen, Merck, Pfizer. ML-Q: Consulting or advisory role—Astellas, AstraZeneca, Bayer, MSD, Pfizer; Speakers’ bureau—Astellas, AstraZeneca, BMS, Eisai, Ipsen, MSD, Pfizer; Research funding—AstraZeneca, BMS, Gilead, Ipsen, MSD, Roche; Travel, accommodations, expenses—Ipsen, MSD, Pfizer. PR: Employment—Ipsen. VP: Employment—Ipsen; Stockholder—Ipsen; Travel, accommodations, expenses—Ipsen. BQ: Employment—Ipsen; Stockholder—Ipsen; Honoraria—Ipsen; Travel, accommodations, expenses—Ipsen. PD: Employment—Ipsen. EV: Consulting or advisory role: AstraZeneca, Bayer, Bristol-Myers Squibb, Eisai, Ipsen, Janssen, Merck Sharp & Dohme, MSD Oncology, Novartis, Pfizer. GP: Consulting or advisory role—Accord, Amgen, Astellas, AstraZeneca, Bayer, Bristol-Myers Squibb, Eisai, EUSA Pharma, Ipsen, Janssen, Lilly, Merck Sharp & Dohme, MSD Oncology, Novartis, Pfizer, Roche Genentech; Research funding—Astellas Pharma, Gilead, Ipsen, Janssen Oncology, MSD; Travel, accommodations, expenses—AAA/Novartis, Ipsen, Janssen, Recordati., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Surgery remains the cornerstone of localized renal cell carcinoma (RCC) care. Pembrolizumab has recently been recommended as a standard of care for RCC patients who are at high risk of recurrence. Data regarding the efficacy of ICIs either alone or in combination with ICIs or VEGF TKIs for VTT shrinkage are scarce., Methods: In the framework of the French kidney cancer research network UroCCR (NCT03293563), we performed a retrospective multicentric European study to evaluate VTT shrinkage in patients treated with ICIs with metastatic or locally advanced renal cell carcinoma (RCC). The primary endpoint was the objective response rate (ORR) of patients with VTT to ICI-based therapy. Radiological assessment was performed by a treating physician according to the RECISTv1.1 criteria., Results: We included 44 patients. The median age was 69 years (range 37-88). All patients was intermediate or poor IMDC risk group. Twenty-three patients were treated with anti-PD-1 in combination with anti-CTLA-4 therapy, 13 patients with ICI monotherapy, and 8 patients with ICIs in combination with antiangiogenic TKI. At baseline, the median VTT diameter was 22 mm (range 7-93). After a median duration of treatment of 5.8 months (range 1.8-39.1), the ORR was 38% (n = 17), including 4 complete responses (CRs) and 13 partial responses (PRs). Ten patients had stable disease (SD), and 17 had progressive disease (PD) as the best response of the VTT., Conclusion: These data highlight the potential efficacy of ICIs to shrink the VTT even if they seem to have little impact on the extent of VTT., Competing Interests: Declarations. Ethical approval: This research has been approved by the local ethics committee. Informed consent: All authors of this research article have approved this article. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Purpose: Immune Checkpoints Inhibitors (ICI) have changed the therapeutic landscape of metastatic renal cell carcinoma first-line treatment with complete response (CR) at metastatic sites observed in 10 to 15% of cases. Delayed nephrectomy could be discussed for patients having a clinical benefit from immunotherapy-based treatment. However, it is unclear whether prior immunotherapy exposure adversely influences the complexity of surgery. The aim of this study was to assess oncological outcomes of differed nephrectomy after immunotherapy, and to identify predictive factors associated with surgical complexity., Methods: This is a multicenter retrospective study from a national cohort of 102 patients treated between March 2015 and March 2023 by differed nephrectomy after complete response (CR) or major partial response (mPR defined as > 80% according to RECIST criteria) on metastatic sites following immunotherapy-based combination treatment. Tumor downsizing was assessed by calculating the percentage reduction from the largest measured tumor diameter, comparing before and after immunotherapy., Results: A total of 102 patients (median age 63.3 years) were included. ICI was administered as first-line in 84.3% of cases, with an ICI-ICI (74.5%) or ICI-TKI combination (25.5%), and with a median duration of treatment of 10 [1-57] months. The majority of procedures are radical nephrectomies (n = 85, 83.3%) with an open approach performed in 52.9% of cases (n = 54). Median operative time was 180 [90-563] minutes and median blood loss was 300 cc [0-4000] cc. Surgeons experienced difficulties due to adhesions and inflammatory reactions at the kidney and the surrounding tissue in 65.7% of cases (n = 67), more frequently in case of partial nephrectomy compared to radical surgery (85% vs. 61%, p = 0.04). In 15 cases (14.7%), the surgical approach changed during the procedure due to these intraoperative difficulties (including 10 patients with open conversion and 3 partial nephrectomies finally converted to radical). We highlighted a relationship between primary renal tumor downsizing and intraoperative complexity. Tumor downsizing > 10% is more likely to induce surgical difficulties (76.1% vs. 45.7%, p = 0.002), but without any impact on postoperative complications rate. Pathology reports show a complete response in 13.7% (n = 14), a pT1-pT2 stage in 29.4% (n = 30) and a pT3-pT4 stage in 56.9% (n = 58), a median ISUP grade 3 and a clear cell carcinoma histology in 95.1% (n = 97). After a median follow-up of 29.6 months, 48% of patients were free from progression and without systemic treatment. Patients with a complete response at the metastatic sites had a better prognosis in terms of recurrence-free survival (82.1% vs. 37.9% at 3 years, p = 0.001)., Conclusion: Delayed nephrectomy after immunotherapy could be a challenging surgical procedure but offers encouraging oncological outcomes., Competing Interests: Declarations. Research involving human participants and/or animals: N/A. Informed consent: N/A. Financial interests: None. Non-financial interests: None. Conflicts of interest: The authors have no conflicts of interest to disclose., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Objective: A hilar location for a renal tumour is sometimes viewed as a limiting factor for safe partial nephrectomy. Our aim was to evaluate perioperative, oncological, and functional outcomes of robot-assisted partial nephrectomy (RAPN) for hilar tumours (RAPN-H) in comparison to RAPN for nonhilar tumours (RAPN-NH)., Methods: We conducted an observational, multicentre cohort study using prospectively collected data from the French Research Network on Kidney Cancer (UroCCR). The registry includes data for 3551 patients who underwent RAPN for localised or locally advanced renal masses between 2010 and 2023 in 29 hospitals in France. We studied the impact of a hilar location on surgery, postoperative renal function, tumour characteristics, and survival. We also compared rates of trifecta achievement (warm ischaemia time [WIT] <25 min, negative surgical margins, and no perioperative complications) between the groups. Finally, we performed a subgroup analysis of RAPN without vascular clamping. Variables were compared in univariable analysis and using multivariable linear, logistic, and Cox proportional-hazards models adjusted for relevant patient and tumour covariates., Key Findings and Limitations: The analytical population included 3451 patients, of whom 2773 underwent RAPN-NH and 678 underwent RAPN-H. Longer WIT (β = 2.4 min; p < 0.01), longer operative time (β = 11.4 min; p < 0.01) and a higher risk of postoperative complications (odds ratio 1.33; p = 0.05) were observed in the hilar group. Blood loss, the perioperative transfusion rate, postoperative changes in the estimated glomerular filtration rate, and trifecta achievement rates were comparable between the groups (p > 0.05). At mean follow-up of 31.9 mo, there was no significant difference in recurrence-free survival (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.58-1.2; p = 0.3), cancer-specific survival (HR 1.1, 95% CI 0.48-2.6; p = 0.79), or overall survival (HR 0.89, 95% CI 0.52-1.53; p = 0.69)., Conclusions and Clinical Implications: Patient and tumour characteristics rather than just hilar location should be the main determinants of the optimal surgical strategy for hilar tumours., Patient Summary: We found that kidney tumours located close to major kidney blood vessels led to a longer operation and a higher risk of complications during robot-assisted surgery to remove the tumour. However, tumours in these locations were not related to a higher risk of kidney function loss, cancer recurrence, or death., (Copyright © 2024 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: The rising incidence of renal cell carcinoma (RCC) is a significant concern in cancer research. This study analyses the characteristics of RCC patients based on their socio-professional category and explores the role of chlorinated solvents as a risk factor., Materials and Methods: A multicentre, descriptive epidemiological study was conducted using the UroCCR database. All patients from participating centres who had been diagnosed with RCC between July 2021 and February 2023, as well as those seen for follow-up consultation during this period, were included. Patients were categorised into 5 socio-professional groups based on INSEE's Profession and Social Categories classification. The characteristics and risk factors of RCC for each group were compared. Binary logistic regression was used to study the exposure to chlorinated solvents and risk factors for clear cell RCC (ccRCC)., Results: A total of 1252 patients were included. Males made up 69.6% of the population. The median age was 64 years, and 87% of the patients had at least one RCC risk factor. ccRCC, papillary, and chromophobe types accounted for 78%, 14.9%, and 8.5% of the population, respectively. The median tumor size was 4.5 cm (SD = 3.3). Farmers had a higher prevalence of ccRCC (91.3%; p = 0.05) and larger tumors (median = 6 cm SD = 3.23; p = 0.038) than patients from other populations. Smoking and obesity rates were lower (10.1%; p < 0.001; 15.9%, p = 0.018, respectively), but exposure to chlorinated solvents was higher (50.7%; p < 0.001). Exposure to chlorinated solvents was independently associated with higher TNM stages (p = 0.044, OR = 1.41 CI (1.01; 1.96)). Obesity and exposure to chlorinated solvents were independent risk factors for ccRCC (p = 0.006, OR = 1.6 CI (1.1;2.2) and p = 0.028, OR = 1.6 CI (1.1;2.6), respectively)., Conclusion: This study shows the influence of socio-professional categories on exposure to RCC risk factors and tumor characteristics. In particular, farmers stood out from the rest of the study population. Their significant exposure to chlorinated solvents could be an interesting factor to investigate., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Objective: To update the French recommendations for the management of kidney cancer., Methods: A systematic review of the literature was conducted for the period from 2014 to 2024. The most relevant articles concerning the diagnosis, classification, surgical treatment, medical treatment, and follow-up of kidney cancer were selected and incorporated into the recommendations. The recommendations have been updated specifying the level of evidence (strong or weak)., Results: Kidney cancer following prolonged occupational exposure to trichloroethylene should be considered an occupational disease. The reference examination for the diagnosis and staging of kidney cancer is the contrast-enhanced thoraco-abdominal CT scan. PET scans are not indicated in the staging of kidney cancer. Percutaneous biopsy is recommended in situations where its results will influence therapeutic decisions. It should be used to reduce the number of surgeries for benign tumors, particularly avoiding unnecessary radical nephrectomies. Kidney tumors should be classified according to the pTNM 2017 classification, the WHO 2022 classification, and the ISUP nucleolar grade. Metastatic kidney cancers should be classified according to IMDC criteria. Surveillance of tumors smaller than 2cm should be prioritized and can be offered regardless of patient age. Robot-assisted laparoscopic partial nephrectomy is the reference surgical treatment for T1 tumors. Ablative therapies and surveillance are options for elderly patients with comorbidities for tumors larger than 2cm. Stereotactic radiotherapy is an option to discuss for treating localized kidney tumors in patients not eligible for other treatments. Radical nephrectomy is the first-line treatment for locally advanced localized cancers. Pembrolizumab is recommended for patients at high risk of recurrence after surgery for localized kidney cancer. In metastatic patients, cytoreductive nephrectomy can be immediate in cases of good prognosis, delayed in cases of intermediate or poor prognosis for patients stabilized by medical treatment, or as "consolidation" in patients with complete or major partial response at metastatic sites after systemic treatment. Surgical or local treatment of metastases can be proposed for single lesions or oligometastases. Recommended first-line drugs for metastatic clear cell renal carcinoma are combinations of axitinib/pembrolizumab, nivolumab/ipilimumab, nivolumab/cabozantinib, and lenvatinib/pembrolizumab. Patients with non-clear cell metastatic kidney cancer should be presented to the CARARE Network and prioritized for inclusion in clinical trials., Conclusion: These updated recommendations are a reference that will enable French and French-speaking practitioners to optimize their management of kidney cancer., (Copyright © 2024 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Background: In 2021, the EAU Guidelines implemented a novel, expert opinion-based follow-up scheme, with a three-risk-category system for clear cell (cc) and non-cc renal cell carcinoma (non-ccRCC) after surgery with curative intent. We aimed to validate the novel follow-up scheme and provide data-driven recurrence estimates according to risk groups, to confirm or implement the oncologic surveillance strategy., Methods: We identified 5,320 patients from a prospectively maintained database involving 28 French referral centers. The risk of recurrence, as either loco-regional or distant, was evaluated with the Kaplan-Meier method for each group (low- intermediate- or high-risk) according to ccRCC or non-ccRCC histology. The noncumulative distribution of recurrences was graphically investigated through the LOWESS smoother., Results: Two thousand two hundred ninety-three (58%), 926 (23%), and 738 (19%) had low-, intermediate, and high-risk ccRCC, and 683 (50%), 297 (22%), and 383 (28%) had low-, intermediate, and high-risk non-ccRCC, respectively. Median follow-up for survivors was 46 months. Overall, 661 patients experienced recurrence. Over time, the noncumulative risk of recurrence was approximately 10% for low-risk cc-RCC, non-ccRCC, and intermediate-risk non-ccRCC, with non-significant difference among the three recurrence functions (P=0.9). At 5-year, time point after which imaging should be de-intensified to biennial, the noncumulative risks of recurrence were: for intermediate risk ccRCC and non-ccRCC: 15% and 11%, respectively; for high-risk ccRCC and non-ccRCC: 24% and 8%, respectively. Among high-risk non-ccRCC patients there were 9 recurrences at 3-month. There was no significant difference between the recurrence function of high-risk non-ccRCC patients with negative imaging at 3-month and the one of intermediate-risk ccRCC (P=0.3)., Conclusions: Given the relatively low recurrence risk of patients with intermediate-risk non-ccRCC, those individuals could be followed up with a similar strategy to the low-risk category. Similarly, patients with high-risk non-ccRCC with negative imaging at 3-month, could be followed up similarly to intermediate-risk ccRCC after the 3-month time point.

Background: Nivolumab is the first immune checkpoint inhibitor approved in Europe for the treatment of advanced renal cell carcinoma (aRCC) in patients resistant to prior antiangiogenic therapy. WITNESS is an ongoing, prospective, observational study designed to evaluate the effectiveness and safety of nivolumab in patients with aRCC treated in real life (or routine practice) in France (ClinicalTrials.gov identifier: NCT03455452)., Patients and Methods: This study includes adult patients with a confirmed diagnosis of aRCC who have initiated nivolumab after 1-2 prior lines of antiangiogenic therapy. Endpoints include overall survival (OS), progression-free survival (PFS), duration of treatment (DOT), duration of response (DOR), overall response rate (ORR), subgroup analyses, and treatment-related adverse events (TRAEs). Results after a median follow-up of 12.3 months are presented here., Results: A total of 325 patients with aRCC were included, of whom 38.2% had a Karnofsky score <80, 77.8% received nivolumab as second-line therapy, and 69.5% had undergone a previous nephrectomy. In the overall population, median OS was 20.5 [95% confidence interval (CI) 17.6-25.0] months and median PFS was 5.2 (95% CI 4.5-5.9) months. ORR was 34.5%, median DOT was 3.8 months, and median DOR was 16.5 months. Nivolumab was effective in different subgroups including patients with bone or glandular metastases and those receiving baseline corticosteroids. Moreover, effectiveness was observed irrespective of prior nephrectomy and line of treatment. No new safety signals were identified; TRAEs of any grade were reported in 32.0% of patients, grade ≥3 and serious TRAEs in 11.1% each, and TRAEs leading to discontinuation in 8.9%., Conclusions: Preliminary results of the ongoing WITNESS study confirm the real-world effectiveness and safety of nivolumab monotherapy in previously treated patients with aRCC. Treatment benefits were similar to those observed in the pivotal phase III CheckMate 025 randomized clinical trial, despite a broader, real-life study population., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: The incidence of localized renal cell carcinoma (RCC) is on the rise among individuals aged 70 and older. While the gold standard for treatment remains surgical resection, some elderly and frail patients with comorbidities are not eligible for this procedure. In selected cases, percutaneous thermal ablation, such as cryotherapy, microwave and radiofrequency, offers less invasive options. General anesthesia is sometimes necessary for such treatments, but most of the procedures can be conducted using mild or deep conscious sedation. This approach is preferably recommended for small cT1a tumors situated at a distance from the renal hilum and/or ureter. Active surveillance remains an alternative in the case of small low grade RCC although it may induce anxiety in certain patients. Recent research has highlighted the potentials of stereotactic ablative body radiotherapy (SABR) as a noninvasive, well-tolerated, and effective treatment for small renal tumors. This narrative review aims to explore recent advances in SABR for localized RCC, including appropriate patient selection, treatment modalities and administration, as well as efficacy and tolerance assessment., Material and Methods: We conducted a literature review using the terms [kidney cancer], [renal cell carcinoma], [stereotactic radiotherapy], [SBRT], and [SABR] in the Medline, PubMed, and Embase databases, focusing on prospective and relevant retrospective studies published in English., Results: Studies report local control rates ranging from 70% to 100% with SABR, highlighting its efficacy in treating RCC. The decline in glomerular filtration rate (GFR) is approximately -5 to -17mL/min over the years following SABR. Common toxicities are rare, primarily CTCAE grade 1, include fatigue, nausea, chest or back pain, diarrhea, or gastritis., Conclusion: Stereotactic ablative body radiotherapy (SABR) may be considered as a viable option for patients with localized RCC who are not suitable candidates for surgery with a high local control rate and a favorable safety profile. This approach should be discussed in a multidisciplinary meeting and results from ongoing clinical trials are awaited., (Copyright © 2024 Société Française du Cancer. All rights reserved.)

Context: Computational pathology is a new interdisciplinary field that combines traditional pathology with modern technologies such as digital imaging and machine learning to better understand the diagnosis, prognosis, and natural history of many diseases., Objective: To provide an overview of digital and computational pathology and its current and potential applications in renal cell carcinoma (RCC)., Evidence Acquisition: A systematic review of the English-language literature was conducted using the PubMed, Web of Science, and Scopus databases in December 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO ID: CRD42023389282). Risk of bias was assessed according to the Prediction Model Study Risk of Bias Assessment Tool., Evidence Synthesis: In total, 20 articles were included in the review. All the studies used a retrospective design, and all digital pathology techniques were implemented retrospectively. The studies were classified according to their primary objective: detection, tumor characterization, and patient outcome. Regarding the transition to clinical practice, several studies showed promising potential. However, none presented a comprehensive assessment of clinical utility and implementation. Notably, there was substantial heterogeneity for both the strategies used for model building and the performance metrics reported., Conclusions: This review highlights the vast potential of digital and computational pathology for the detection, classification, and assessment of oncological outcomes in RCC. Preliminary work in this field has yielded promising results. However, these models have not yet reached a stage where they can be integrated into routine clinical practice., Patient Summary: Computational pathology combines traditional pathology and technologies such as digital imaging and artificial intelligence to improve diagnosis of disease and identify prognostic factors and new biomarkers. The number of studies exploring its potential in kidney cancer is rapidly increasing. However, despite the surge in research activity, computational pathology is not yet ready for widespread routine use., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: Clear cell renal cell carcinoma (ccRCC) is characterized by a predominant metabolic reprogramming triggering energy production by anaerobic glycolysis at the expense of oxydative phosphorylation. Ketogenic diet (KD), which consists of high fat and low carbohydrate intake, could bring required energy substrates to healthy cells while depriving tumor cells of glucose. Our objective was to evaluate the effect of KD on renal cancer cell tumor metabolism and growth proliferation., Methods: Growth cell proliferation and mitochondrial metabolism of ACHN and Renca renal carcinoma cells were evaluated under ketone bodies (KB) exposure. In vivo studies were performed with mice (nude or Balb/c) receiving a xenograft of ACHN cells or Renca cells, respectively, and were then split into 2 feeding groups, fed either with standard diet or a 2:1 KD ad libitum. To test the effect of KD associated to immunotherapy, Balb/c mice were treated with anti-PDL1 mAb. Tumor growth was monitored., Results: In vitro , KB exposure was associated with a significant reduction of ACHN and Renca cell proliferation and viability, while increasing mitochondrial metabolism. In mice, KD was associated with tumor growth reduction and PDL-1 gene expression up-regulation. In Balb/c mice adjuvant KD was associated to a better response to anti-PDL-1 mAb treatment., Conclusion: KB reduced the renal tumor cell growth proliferation and improved mitochondrial respiration and biogenesis. KD also slowed down tumor growth of ACHN and Renca in vivo . We observed that PDL-1 was significantly overexpressed in tumor in mice under KD. Response to anti-PDL-1 mAb was improved in mice under KD. Further studies are needed to confirm the therapeutic benefit of adjuvant KD combined with immunotherapy in patients with kidney cancer., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Richard, Beauvillain, Benoit, Barth, Aubert, Rolley, Bellal, Bourreau, Ferragu, Lebdai, Chevrollier, Henrion, Procaccio and Bigot.)

Here, in a multi-ancestry genome-wide association study meta-analysis of kidney cancer (29,020 cases and 835,670 controls), we identified 63 susceptibility regions (50 novel) containing 108 independent risk loci. In analyses stratified by subtype, 52 regions (78 loci) were associated with clear cell renal cell carcinoma (RCC) and 6 regions (7 loci) with papillary RCC. Notably, we report a variant common in African ancestry individuals ( rs7629500 ) in the 3' untranslated region of VHL, nearly tripling clear cell RCC risk (odds ratio 2.72, 95% confidence interval 2.23-3.30). In cis-expression quantitative trait locus analyses, 48 variants from 34 regions point toward 83 candidate genes. Enrichment of hypoxia-inducible factor-binding sites underscores the importance of hypoxia-related mechanisms in kidney cancer. Our results advance understanding of the genetic architecture of kidney cancer, provide clues for functional investigation and enable generation of a validated polygenic risk score with an estimated area under the curve of 0.65 (0.74 including risk factors) among European ancestry individuals., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: There is limited evidence on the outcomes of robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN) in obese patients (BMI ≥ 30 kg/m 2 ). In this study, we aimed to compare perioperative and oncological outcomes of RPN and OPN., Methods: We relied on data from patients who underwent PN from 2009 to 2017 at 16 departments of urology participating in the UroCCR network, which were collected prospectively. In an effort to adjust for potential confounders, a propensity-score matching was performed. Perioperative outcomes were compared between OPN and RPN patients. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method and compared using the log-rank test., Results: Overall, 1277 obese patients (932 robotic and 345 open were included. After propensity score matching, 166 OPN and 166 RPN individuals were considered for the study purposes; no statistically significant difference among baseline demographic or tumor-specific characteristics was present. A higher overall complication rate and major complications rate were recorded in the OPN group (37 vs. 25%, p = 0.01 and 21 vs. 10%, p = 0.007; respectively). The length of stay was also significantly longer in the OPN group, before and after propensity-score matching (p < 0.001). There were no significant differences in Warm ischemia time (p = 0.66), absolute change in eGFR (p = 0.45) and positive surgical margins (p = 0.12). At a median postoperative follow-up period of 24 (8-40) months, DFS and OS were similar in the two groups (all p > 0.05)., Conclusions: In this study, RPN was associated with better perioperative outcomes (improvement of major complications rate and LOS) than OPN. The oncological outcomes were found to be similar between the two approaches., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Partial nephrectomy (PN) for large or complex renal tumors can be difficult and associated with a higher risk of recurrence than radical nephrectomy. We aim to evaluate the clinical useful of nephrometry scores for predicting oncological outcomes in a large cohort of patients who underwent PN for renal cell carcinomas., Methods: Our analysis included patients who underwent PN for renal cell carcinoma in 21 French academic centers (2010-2020). RENAL, PADUA, and SPARE scores were calculated based on preoperative imaging. Uni- and multivariate cox models were performed to identify predictors of recurrence-free survival and overall survival. The area under the curve (AUC) was used to identify models with the highest discrimination. Decision curve analyses (DCAs) determined the net benefit associated with their use., Results: A total of 1927 patients were analyzed with a median follow-up of 32 months (14-45). RENAL score (p = 0.01), age (p = 0.002), histological type (p = 0.001), high nuclear grade (p = 0.001), necrotic component (p < 0.001), and positive margins (p = 0.005) were significantly related to recurrence in multivariate analyses. The discriminative performance of the 3 radiological scores was modest (65, 63, and 63%, respectively). All 3 scores showed good calibration, which, however, deteriorated with time. Decision curve analysis of the three models for the prediction of overall and recurrence-free survival was similar for all three scores and of limited clinical relevance., Conclusion: The association between nephrometry scores and oncological outcomes after NP is very weak. The use of these scores for predicting oncological outcomes in routine practice is therefore of limited clinical value., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To compare the oncological and perioperative outcomes of robot-assisted partial nephrectomy (RPN) and percutaneous thermal ablation (PTA) for treatment of T1 renal cell cancer (RCC) in patients older than 75 years., Materials and Methods: Retrospective national multicenter study included all patients older than 75 years treated for a T1 RCC by RPN or PTA between January 2010 and January 2021. Patients' characteristics, tumor data, and perioperative and oncological outcomes were compared., Results: A total of 205 patients for 209 procedures (143 RPN and 66 PTA) were included. In the PTA group, patients were older (80.4 ± 3.7 vs. 79 ± 3.7 years (p = 0.01)); frailer (ASA score (2.43 ± 0.6 vs. 2.17 ± 0.6 (p < 0.01)); and more frequently had a history of kidney surgery (16.7% [11/66] vs. 5.6% [8/143] (p = 0.01)) than in the RPN group. Tumors were larger in the RPN group (2.7 ± 0.7 vs. 3.2 ± 0.9 cm (p < 0.01)). Operation time, length of hospital stay, and increase of creatinine serum level were higher in RPN (respectively 92.1 ± 42.7 vs. 150.7 ± 61.3 min (p < 0.01); 1.7 ± 1.4 vs. 4.2 ± 3.4 days (p < 0.01); 1.9 ± 19.3% vs. 10.1 ± 23.7 (p = 0.03)). Disease-free survival and time to progression were similar (respectively, HR 2.2; 95% CI 0.88-5.5; p = 0.09; HR 2.1; 95% CI 0.86-5.2; p = 0.1). Overall survival was shorter for PTA that disappeared after Cox adjusting model (HR 3.3; 95% CI 0.87-12.72; p = 0.08)., Conclusion: Similar oncological outcomes are observed after PTA and RPN for T1 RCC in elderly patients., Clinical Relevance Statement: Robot-assisted partial nephrectomy and percutaneous thermal ablation have similar oncological outcomes for T1a kidney cancer in patients over 75 years; however, operative time, decrease in renal function, and length of hospital stay were lower with ablation., Key Points: • After adjusting model for age and ASA score, similar oncological outcomes are observed after percutaneous thermal ablation and robot-assisted partial nephrectomy for T1 renal cell cancer in elderly patients. • Operation time, length of hospital stay, and increase of creatinine serum level were higher in the robot-assisted partial nephrectomy group., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Background: The SPARE Nephrometry Score (NS) is described as easier to implement than the RENAL and PADUA NSs, currently more widely used. Our objective was to compare the accuracy of SPARE NS in predicting renal function outcomes following RAPN., Methods: A multicentric retrospective study was conducted using French kidney cancer network (UroCCR, NCT03293563) database. All patients included had RAPN for cT1 renal tumors between May 2010 and March 2021. SPARE was compared to RENAL, PADUA and Tumor Size to predict postoperative acute kidney injury (AKI), chronic kidney disease (CKD) upstaging, de novo CKD at 3-6 months follow-up and Trifecta failure. The ability of the different NSs and tumor size to predict renal function outcomes was evaluated using uni- and multivariate logistic regression models., Results: According to our study criteria, 1171 patients were included. Mean preoperative tumor size and estimated glomerular filtration rate (eGFR) were 3.4±1.4 cm and 85.8 mL/min/1.73 m 2 . In total, 266 (22.7%), 87 (7.4%), 94 (8%), and 624 (53.3%) patients had AKI, de novo CKD, CKD upstaging, and Trifecta failure, respectively. In multivariate analysis, all three NSs and tumor size were independent predictors of AKI, CKD de novo, CKD upgrade and Trifecta failure. There was no significant difference between all three NS and tumor sizes in predicting renal function outcomes., Conclusions: SPARE Score seems to be a valid alternative to predict renal function outcomes after RAPN. Nevertheless, in our study, tumor size was as accurate as NSs in predicting postoperative outcomes and, therefore, seems to be the logical choice for surgical decisions.

Objective: Renal cell carcinomas represent the sixth- and tenth-most frequently diagnosed cancer in men and women. Recently, percutaneous-guided thermal ablations have proved to be as effective as partial nephrectomy and safer for treating small renal masses (i.e.,  < 3 cm). This study compared the perioperative and recurrence outcomes of percutaneous thermal ablation (TA) and robotic-assisted partial nephrectomy (RAPN) for the treatment of T1b renal cell carcinomas (4.1-7 cm)., Methods: Retrospective data from 11 centers on the national database, between 2010 and 2020, included 81 patients treated with thermal ablation (TA) and 308 patients treated with RAPN for T1b renal cell carcinoma, collected retrospectively and matched for tumor size, histology results, and the RENAL score. TA included cryoablation and microwave ablation. Endpoints compared the rate between the two groups: local recurrence, metastases, complications, renal function decrease, and length of hospitalization., Results: After matching, 75 patients were included in each group; mean age was 76.6 (± 9) in the TA group and 61.1 (± 12) in the RAPN group, including 69.3% and 76% men respectively. The local recurrence (LR) rate was significantly higher in the TA group than in the PN group (14.6% vs 4%; p = 0.02). The LR rate was 20% (1/5) after microwave ablation, 11.1% (1/9) after radiofrequency ablation, and 14.7% (9/61) after cryoablation. The major complication rate (Clavien-Dindo  ≥ 3) was higher following PN than after TA (5.3% vs 0%; p < 0.001). Metastases, eGFR decrease, and length of hospitalization did not differ significantly between the two groups., Conclusions: The local recurrence rate was significantly higher after thermal ablation; however, thermal ablation resulted in significantly lower rates of complications. Thermal ablation and robotic-assisted partial nephrectomy are effective treatments for T1b renal cancer; however, the local recurrence rate was higher after thermal ablation., Key Points: • The local recurrence rate was significantly higher in the thermal ablation group than in the partial nephrectomy group. • The major complication rate (Clavien-Dindo ≥ 3) was higher following PN than after TA (5.3% vs. 0%; p < 0.001)., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Objectives: To assess the impact of pathological upstaging from clinically localized to locally advanced pT3a on survival in patients with renal cell carcinoma (RCC), as well as the oncological safety of various surgical approaches in this setting, and to develop a machine-learning-based, contemporary, clinically relevant model for individual preoperative prediction of pT3a upstaging., Materials and Methods: Clinical data from patients treated with either partial nephrectomy (PN) or radical nephrectomy (RN) for cT1/cT2a RCC from 2000 to 2019, included in the French multi-institutional kidney cancer database UroCCR, were retrospectively analysed. Seven machine-learning algorithms were applied to the cohort after a training/testing split to develop a predictive model for upstaging to pT3a. Survival curves for disease-free survival (DFS) and overall survival (OS) rates were compared between PN and RN after G-computation for pT3a tumours., Results: A total of 4395 patients were included, among whom 667 patients (15%, 337 PN and 330 RN) had a pT3a-upstaged RCC. The UroCCR-15 predictive model presented an area under the receiver-operating characteristic curve of 0.77. Survival analysis after adjustment for confounders showed no difference in DFS or OS for PN vs RN in pT3a tumours (DFS: hazard ratio [HR] 1.08, P = 0.7; OS: HR 1.03, P > 0.9)., Conclusions: Our study shows that machine-learning technology can play a useful role in the evaluation and prognosis of upstaged RCC. In the context of incidental upstaging, PN does not compromise oncological outcomes, even for large tumour sizes., (© 2023 The Authors. BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Background: Predictive tools can be useful for adapting surveillance or including patients in adjuvant trials after surgical resection of nonmetastatic renal cell carcinoma (RCC). Current models have been built using traditional statistical modelling and prespecified variables, which limits their performance., Objective: To investigate the performance of machine learning (ML) framework to predict recurrence after RCC surgery and compare them with current validated models., Design, Setting, and Participants: In this observational study, we derived and tested several ML-based models (Random Survival Forests [RSF], Survival Support Vector Machines [S-SVM], and Extreme Gradient Boosting [XG boost]) to predict recurrence of patients who underwent radical or partial nephrectomy for a nonmetastatic RCC, between 2013 and 2020, at 21 French medical centres., Outcome Measurements and Statistical Analysis: The primary end point was disease-free survival. Model discrimination was assessed using the concordance index (c-index), and calibration was assessed using the Brier score. ML models were compared with four conventional prognostic models, using decision curve analysis (DCA)., Results and Limitations: A total of 4067 patients were included in this study (3253 in the development cohort and 814 in the validation cohort). Most tumours (69%) were clear cell RCC, 40% were of high grade (nuclear International Society of Urological Pathology grade 3 or 4), and 24% had necrosis. Of the patients, 4% had nodal involvement. After a median follow-up of 57 mo (interquartile range 29-76), 523 (13%) patients recurred. ML models obtained higher c-index values than conventional models. The RSF yielded the highest c-index values (0.794), followed by S-SVM (c-index 0.784) and XG boost (c-index 0.782). In addition, all models showed good calibration with low integrated Brier scores (all integrated brier scores <0.1). However, we found calibration drift over time for all models, albeit with a smaller magnitude for ML models. Finally, DCA showed an incremental net benefit from all ML models compared with conventional models currently used in practice., Conclusions: Applying ML approaches to predict recurrence following surgical resection of RCC resulted in better prediction than that of current validated models available in clinical practice. However, there is still room for improvement, which may come from the integration of novel biological and/or imaging biomarkers., Patient Summary: We found that artificial intelligence algorithms could better predict the risk of recurrence after surgery for a localised kidney cancer. These algorithms may help better select patients who will benefit from medical treatment after surgery., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction and Objectives: Many patients in the favorable International Metastatic renal cell carcinoma (RCC) Data Base Consortium group (F-MRC) may have a relatively indolent disease course. Surveillance and delay of systemic therapy could be an option in this specific population. However, the question whether this delay could alter patients' outcome remains unanswered. Our objective was to determine if delaying first-line treatment influences the survival of F-MRC patients., Materials and Methods: We performed a retrospective multicenter national study involving the French Network for Research on Kidney Cancer UroCCR (NCT03293563). We included treatment naive F-MRC patients. We compared the overall survival of patients with immediate medical treatment (IMT) (started less than 3 months after metastatic diagnosis) to those with delayed medical treatment (DMT)., Results: We included 90 patients treated between 2009 and 2018. The median time before occurrence of metastases from diagnosis was 28 (12-137) months. The two groups (IMT vs. DMT) were comparable for follow-up, age, sarcomatoid feature, number, and localization of metastatic sites and ECOG performance status. IMT was given in 25 (27.8 %) patients. Local treatment of metastasis (LTM) was performed in 47 (52%) patients. Patients with DMT had more LTM (63% vs. 24%, P = .001). Among patients with DMT (n = 65); 27 (41%) received a systemic treatment and median systemic treatment-free survival was 39 months (95% CI, 26.3-51.6). Median overall survival from metastasis disease diagnosis was 55 months (95% CI, 42.4-67.5) in the IMT group and 88 months (95%CI, 64-111.9) in the DMT group (P = .028). In multivariable analysis LTM was the only prognostic factor associated to survival improvement (HR: 0.33; P = .024)., Conclusions: Selected Patients with F-MRC may safely undergo DMT. LTM positively impacted survival in this population and should be considered whenever possible. Prospective trial with a larger population is needed to confirm these results., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To describe clinical features of patients with oncocytoma on renal biopsy (RMB), correlation with final histology on surgically treated patients, and predictive factors of discrepancy between RMB and final histology., Methods: This was a retrospective study conducted in the framework of the UroCCR project (NCT03293563). All tumors with oncocytoma on RMB were selected and all pathological reports were reviewed. Patients with the RMB simultaneously performed with a focal treatment, synchronous bilateral tumors and ambiguous RMB report were excluded. Discrepancy between RMB and definitive histology was evaluated using a uni- and multivariable logistic regression analyses model., Results: Overall, 119 tumors with oncocytoma on RMB, from 15 centers, were included. Of those, 54 (45.4%) had upfront surgery and 65 (54.6%) had active surveillance (AS). In renal masses with initial active surveillance, with a median follow-up of 28 months, 23 (19.3%) underwent surgery, 4 (3.4%) received focal treatment and 38 (31.9%) remained on AS. On final pathology, only 51 of the 75 surgically treated tumors (68.0%) had oncocytoma, while 24 presented malignant tumors (mainly chromophobe carcinoma (19.2%), and hybrid oncocytic/chromophobe tumor (HOCT) (6.8%)) leading to a discrepancy of 32.0% between RMB and final pathology. The only predictive factor of a discrepancy between RMB and definitive histology was a biopsy done outside of the center (Odds ratio: 3.22 [95%-confidence interval: 1.08-9.61], p = 0.03)., Conclusion: Despite the increase of RMB in more and more centers, histologic discrepancy between RMB and definitive histology remains significant. This information should be discussed with patients and taken into consideration before treatment decision., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To assess the oncological outcomes of renal cell carcinoma (RCC) associated with tumor thrombus and identify predictive factors of recurrence., Methods: Multi-institutional study that included patients with cT3-4N0-1M0 RCC with tumoral thrombus identified in the prospective UroCCR database (CNIL DR 2013-206; NCT03293563). pT3a without involvement of the renal vein were excluded. All patients underwent radical nephrectomy and a thrombectomy of the renal vein ± inferior vena cava ± right atrium. The primary endpoint was recurrence-free survival (RFS). Thirty-two patients who had adjuvant therapies (tyrosine kinase inhibitors or mTOR inhibitor) were compared to control group (surveillance) in a propensity score-matched 1:1 sub-analysis RESULTS: A total of 432 patients were included: 70.4% pT3a, 20.1% pT3b, 4.2% pT3c and 5.3% pT4. Tumor characteristics were: 90.7% clear cell RCC, 13.9% pN1, and 87.1% high Fuhrman grade. 173 patients (40%) had disease recurrence, and median RFS was 37.3 months (95% CI, 26.4-46.7). In a multivariate analysis (Cox model), predictive factors of recurrence were: pT4 (HR 2.66; 95% CI, 1.42-4.99; p = 0.002), pN1 (HR 2.53; 95% CI, 1.46-4.39; p < 0.001), tumor necrosis (HR 2.92; 95% CI, 1.85-4.62; p < 0.001), tumor size > 10 cm (HR 1.56; 95% CI, 1.08-2.24; p = 0.018). Adjuvant therapy was a protective factor of cancer recurrence (HR 0.33; 95% CI, 0.17-0.66; p = 0.002). Propensity score-matched sub-analysis of adjuvant vs control (surveillance) confirmed adjuvant treatment as a protective factor of cancer recurrence (Log rank p = 0.015)., Conclusions: In this contemporary multi-institutional cohort of RCC + tumor thrombus, we reported higher recurrence rate shortly after surgical excision and demonstrated an oncological benefit of adjuvant treatment., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The management of solitary kidney tumors is a surgical challenge, requiring irreproachable results on both oncological and functional outcomes. The goal of our study was to compare the perioperative results of robotic-assisted partial nephrectomy (RAPN) to open surgery in this indication., Methods: We led a multicentric study based on the prospectively maintained French national database UroCCR. Patients who underwent partial nephrectomy on a solitary kidney between 1988 and 2020 were included. Clinical and pathological data were retrospectively analyzed. The main outcome of the study was the analysis of the variation of the estimated glomerular filtration rate (eGFR) calculated according to MDRD at 3, 6, 12, and 24 months depending on the chosen surgical approach. The secondary outcomes were the comparison of Trifecta success, perioperative complications, and length of hospital stay., Results: In total, 150 patients were included; 68 (45%) in the RAPN group and 82 (55%) in the open surgery group. The two groups were comparable for all data. The variation of eGFR at 3, 6, 12, or 24 months was comparable without any significant difference between the 2 groups (p = 0.45). Trifecta was achieved in 40% of the patients in the RAPN group and 33% in the open group (p = 0.42). A significant difference was observed for the length of stay, 5 days for the robot group versus 9 days for the open surgery group (p < 0.0001)., Conclusion: In our study, the surgical approach did not modify functional results and we noted a significant decrease in hospital stay and complications in the RAPN group. RAPN is a safe and efficient method for management of kidney tumors in solitary kidneys., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Partial nephrectomy is the treatment of choice for small localized renal tumors. In case of doubt, a biopsy can confirm the diagnosis. The aim of this study was to evaluate the impact of a delayed time to partial nephrectomy on cancer development., Materials and Methods: Our single center study enrolled localized renal tumor patients who underwent a partial nephrectomy between 2015 and 2020; the collected data were included in the uroCCR prospective database. The histopathological stage of the tumors and the recurrence rate in patients treated with surgery >90 days after diagnosis were investigated. The impact a preoperative biopsy on was also explored. Statistical significance was tested using Student's t-test and Chi-squared test (SPSS software)., Results: The cohort consisted of 179 patients, among which 41 (23 %) received a preoperative biopsy. 89 patients (50 %) were treated surgically >3 months after diagnosis. The median time to nephrectomy was 86 days (13-1 037). A delayed time to surgery did not lead to significantly higher recurrence rates (P=0.66). Preoperative biopsy led to a doubling time to surgery (P<0.001) but was neither correlated to a more severe tumor stage (P=0.944) nor to a higher recurrence rate (P=0.08). Tumor growth was not significantly different with or without the presence of a biopsy (P=0.122)., Conclusion: Our data evidence that a substantial delayed time to partial nephrectomy does not result in a negative impact on cancer prognosis in localized renal tumor patients., (Copyright © 2022. Published by Elsevier Masson SAS.)

We compared the outcomes of robotic-assisted partial nephrectomy (RPN) and open partial nephrectomy (OPN) using contemporary data to respond to unmet clinical needs. Data from patients included in the registry who underwent partial nephrectomy between January 01, 2014 and June 30, 2017 within 20 centres of the French Network for Research on Kidney Cancer UroCCR were collected (NCT03293563). Statistical methods included adjusted multivariable analyses. Rates of peri- and post-operative transfusion, and of surgical revision, were lower in the RPN (n = 1434) than the OPN (n = 571) group (2.9% vs. 6.0%, p = 0.0012; 3.8% vs. 11.5%, p < 0.0001; 2.4% vs. 6.7%, p < 0.0001, respectively). In multivariable analyses, RPN was independently associated with fewer early post-operative complications than OPN (overall: odds-ratio [95% confidence interval, CI] = 0.48 [0.35-0.66]; severe: 0.29 [0.16-0.54], p < 0.0001 for both) and shorter hospital stays (34% [30%; 37%], p < 0.0001). RPN was also a significantly associated with a decresedrisk of post-operative acute renal failure, and new-onset chronic kidney disease at 3 and 12 months post-surgery. There were no between-group differences in oncological outcomes. In comparison with OPN, RPN was associated with improved peri- and post-operative morbidity, better functional outcomes, and shorter hospital stays. Our results support the use of RPN, even for large and complex tumours., (© 2022. The Author(s).)

Objective: Off-clamp laparoscopic partial nephrectomy in a hybrid operating room after superselective arterial embolization (hLPN) is a promising minimally invasive approach. In this study, we compared the perioperative surgical outcomes of this innovative technique with the conventional standard of care laparoscopic partial nephrectomy (cLPN) technique., Patients and Methods: Overall, 86 and 127 patients treated with hLPN and cLPN, respectively, were included. These two techniques were compared in terms of surgical complications, estimated blood loss (EBL), operative time, length of stay (LOS), surgical margins, and Trifecta achievement rate (defined as warm ischemia duration <25 min, negative surgical margins and absence of complications). A propensity score based on age, gender, BMI, preoperative eGFR and tumor size was used for a 1:1 matching of patients of each group. After matching, 2 groups of 67 patients with similar characteristics were obtained., Results: Conversion rate to open surgery, complications and EBL were similar in both groups. Conversely, operative time, LOS and Trifecta rates favored hLPN. The multivariate analysis showed that hLPN had a 70% higher chance of Trifecta achievement than cLPN in all age groups and for all tumor size across the study population., Conclusion: Compared to a conventional approach, off-clamp laparoscopic partial nephrectomy in a hybrid room after superselective arterial embolization showed satisfying immediate surgical outcomes and reached a higher rate of Trifecta achievement. Mid and long-term functional and oncological results are needed to establish this minimally invasive surgical alternative., (Copyright © 2022. Published by Elsevier España, S.L.U.)

Aim: To update the recommendations for the management of kidney cancers., Methods: A systematic review of the literature was conducted from 2015 to 2022. The most relevant articles on the diagnosis, classification, surgical treatment, medical treatment and follow-up of kidney cancer were selected and incorporated into the recommendations. Therefore, the recommendations were updated while specifying the level of evidence (high or low)., Results: The gold standard for the diagnosis and evaluation of kidney cancer is contrast-enhanced chest and abdominal CT. MRI and contrast-enhanced ultrasound are indicated in special cases. Percutaneous biopsy is recommended in situations where the results will influence the therapeutic decision. Renal tumours should be classified according to the pTNM 2017 classification, the WHO 2022 classification and the ISUP nucleolar grade. Metastatic kidney cancer should be classified according to the IMDC criteria. Partial nephrectomy is the gold standard treatment for T1a tumours and can be performed by an open approach, by laparoscopy or by robot-guidance. Active surveillance of tumours less than 2cm in size can be considered regardless of the patient's age. Ablative therapies and active surveillance are options in elderly patients with comorbidity. T1b tumours should be treated by partial or radical nephrectomy depending on the complexity of the tumour. Radical nephrectomy is the first-line treatment for locally advanced cancers. Adjuvant treatment with pembrolizumab should be considered in patients at intermediate and high risk for recurrence after nephrectomy. In metastatic patients: Immediate cytoreductive nephrectomy may be offered to oligometastatic patients in combination with local treatment of metastases if this can be complete and delayed cytoreductive nephrectomy can be proposed for patients with a complete response or a significant partial response. Medical treatment should be proposed as first-line therapy for patients with a poor or intermediate prognosis. Surgical or local treatment of metastases can be proposed in case of single or oligo-metastases. The recommended first-line drugs for metastatic patients with clear cell renal carcinoma are the combinations axitinib/pembrolizumab, nivolumab/ipililumab, nivolumab/cabozantinib and lenvatinib/pembrolizumab. Cabozantinib is the recommended first-line treatment for patients with metastatic papillary carcinoma. Cystic tumours should be classified according to the Bosniak classification. Surgical removal should be proposed as a priority for Bosniak III and IV lesions. It is recommended that patient monitoring be adapted to the aggressiveness of the tumour., Conclusion: These updated recommendations are a reference that will allow French and French-speaking practitioners to improve kidney cancer management., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Background: In the current era of immune checkpoint inhibitors (ICIs), the role and optimal timing of a nephrectomy in patients with metastatic renal cell carcinoma (mRCC) remain unknown., Objective: To assess the oncological outcomes of patients who responded to ICI-based treatments and were subsequently treated with a delayed nephrectomy., Design, Setting, and Participants: This national retrospective evaluation included 30 patients with mRCC who underwent a nephrectomy after a complete response (CR) or a major partial response (>80%) to ICI treatment at metastatic sites., Intervention: Partial or radical nephrectomy after a favorable response to ICI treatment., Outcome Measurements and Statistical Analysis: Disease-free survival (DFS), progression-free survival (PFS), overall survival (OS), and potential discontinuation of systemic treatment were assessed., Results and Limitations: ICI-based treatments included ipilimumab-nivolumab (40%), ICI + tyrosine kinase inhibitor (10%), and nivolumab (50%). A delayed nephrectomy was performed after a median ICI treatment duration of 10 mo. In 19 cases (63.3%), surgeons faced difficulties due to adhesions or inflammatory changes. A complete pathological response was observed in 16.7% of patients. After a median follow-up of 19.5 mo after nephrectomy, 76.7% of patients achieved DFS. At 1 yr, 66.7% of patients were free from systemic treatment. The PFS and OS rates were, respectively, 96.7% and 100% at 1 yr, and 78.3% and 86.1% at 2 yr. Patients with a CR at metastatic sites had a better prognosis than those with a major partial response, in terms of DFS (p = 0.022) and PFS (p = 0.014)., Conclusions: Despite potentially challenging surgery, a delayed nephrectomy for patients who responded to ICI treatment provided promising oncological outcomes, and the majority of patients could discontinue systemic treatment., Patient Summary: In this study, we evaluated the clinical outcome in patients who responded well to immunotherapy, and subsequently underwent kidney ablation surgery. Three-quarters of patients experienced no recurrence, and in most cases, medical treatment could be discontinued., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: The prognostic impact of renal cell carcinoma (RCC) morphotype remains unclear in patients who undergo partial nephrectomy (PN). Our objective was to determine the risk factors for recurrence after PN, including RCC morphotype., Methods: Patients with RCC who had undergone PN were extracted from the prospective, national French database, UroCCR. Patients with genetic predisposition, bilateral or multiple tumours, and those who had undergone secondary totalization were excluded. Primary endpoint was 5-year, recurrence-free survival (RFS), and secondary endpoint was overall survival (OS). Risk factors for recurrence were assessed by multivariable Cox regression analysis., Results: Overall, 2,767 patients were included (70% male; median age: 61 years [interquartile range (IQR) 51-69]). Most (71.5%) of the PN procedures were robot-assisted. Overall, 2,573 (93.0%) patients were recurrence free, and 74 died (2.7%). Five-year RFS was 84.9% (IQR 82.4-87.4). A significant difference in RFS was observed between RCC morphotypes (p < 0.001). Surgical margins (hazard ratio [HR] = 2.0 [95% confidence interval (CI): 1.3-3.2], p < 0.01), pT stage >1 (HR = 2.6 [95% CI: 1.8-3.7], p < 0.01]) and Fuhrmann grade >2 (HR = 1.9 [95% CI: 1.4-2.6], p < 0.001) were risk factors for recurrence, whereas chromophobe subtype was a protective factor (HR = 0.08 [95% CI: 0.01-0.6], p = 0.02). Five-year OS was 94.0% [92.4-95.7], and there were no significant differences between RCC subgroups (p = 0.06). The main study limitation was its design (multicentre national database), which may be responsible for declarative bias., Conclusions: Chromophobe morphotype was significantly associated with better RFS in RCC patients who underwent PN. Conversely, pT stage, Fuhrman group and positive surgical margins were risk factors for recurrence., (© 2022. Society of Surgical Oncology.)

Background: Data comparing percutaneous ablation (PCA) and surgical resection (SR) for an isolated local recurrence (LR) following partial nephrectomy (PN) for renal cell carcinoma (RCC) are lacking., Objective: To examine the outcomes between PCA and SR for an isolated LR following PN for RCC., Design, Setting, and Participants: Patients who underwent PN for RCC and developed an LR between 2013 and 2019 were included. An LR was defined as the appearance of a mass in contact with the resection bed or the development of a tumor in the same region of the homolateral kidney as the original site., Intervention: PCA or SR., Outcome Measurements and Statistical Analysis: To achieve balance in baseline characteristics, we used inverse probability of treatment weighting (IPTW) based on propensity to receive treatment. Oncological outcomes, complications, and renal function were evaluated between groups using logistic, linear, and Cox proportional hazard regression models., Results and Limitations: A total of 81 patients with an isolated LR were included (PCA: 42; SR: 39). The median follow-up was 23 mo. After adjustment, excellent balance was achieved for the majority of propensity score variables. In IPTW analysis, PCA was associated with a lower risk of postoperative complications (odds ratio=0.22; p=0.006) and a smaller change in eGFR (beta=-16.18; p=0.001). There were no significant differences in the risk of disease recurrence (hazard ratio [HR]=0.72; p=0.61), new LR (HR=1.51; p=0.59), and distant metastasis (HR=0.19; p=0.09). Limitations include the sample size and unmeasured confounding factors., Conclusions: Our results suggest that PCA provides comparable oncological outcomes to repeat surgery with fewer complications and better renal function preservation for the management of an LR after PN., Patient Summary: This report shows that percutaneous ablation can be used for treating a local recurrence of renal cell carcinoma after partial nephrectomy, without significantly compromising cancer control., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: The current pathological tumour-node-metastasis (pTNM) classification for upper tract urothelial carcinoma (UTUC) does not include any risk stratification of pT3 renal pelvicalyceal tumours., Objective: To assess the prognostic impact of pT3 subclassification in a multicentre cohort of patients with UTUC of the renal pelvicalyceal system undergoing radical nephroureterectomy (RNU)., Design, Setting, and Participants: Data from all consecutive patients treated with RNU for pT3 renal pelvicalyceal UTUC at 14 French centres from 1995 to 2013 were reviewed retrospectively., Intervention: A central pathology review (CPR) was used to stratify pT3 patients into those with infiltration of the renal parenchyma on a microscopic level (pT3a) versus those with infiltration of the renal parenchyma visible on gross inspection of the resection specimen and/or invasion of peripelvic fat (pT3b)., Outcome Measurements and Statistical Analysis: Inverse probability weighting (IPW)-adjusted Cox regression analyses were used to compare recurrence-free survival (RFS) and cancer-specific survival (CSS) between pT3a and pT3b patients., Results and Limitations: Overall, 202 patients were included and further stratified into pT3a (n = 98; 48.5%) and pT3b (n = 104; 51.5%) subgroups. Median time to follow-up in the weighted population was 68 (interquartile range, 50-95) mo. In IPW-adjusted Cox regression analyses, pT3b versus pT3a substage was associated with a significant adverse effect on RFS (hazard ratio [HR] = 2.02; 95% confidence interval [CI] = [1.36-3.01]; p < 0.001) and CSS (HR = 1.84; 95% CI = [1.20-2.82]; p = 0.005). The study is limited by its retrospective design., Conclusions: Using IPW-adjusted analyses after the CPR, we observed that RNU patients with pT3b renal pelvicalyceal UTUC had adverse prognosis as compared with those with pT3a disease. As such, this subclassification could help refine the current pTNM system for UTUC., Patient Summary: In this report, we looked at the prognostic interest of stratifying patients with pT3 renal pelvicalyceal upper tract urothelial carcinoma based on the extent of local invasion. We found that those with extensive infiltration (pT3b) had adverse prognosis as compared with those with limited infiltration (pT3a). This information could be provided on pathology reports to further guide clinical decision making., (Copyright © 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

To describe clinical outcomes of patients aged 75 years and above after partial nephrectomy (PN), and to assess independent factors of postoperative complications. We retrospectively reviewed information from our multi-institutional database. Every patient over 75 years old who underwent a PN between 2003 and 2016 was included. Peri-operative and follow up data were collected. Multivariate logistic regression was performed to determine independent predictive factors of postoperative complications. We reviewed 191 procedures including 69 (40%) open-surgery, and 122 (60%) laparoscopic procedures, of which 105 were robot-assisted. Median follow-up was 25 months. The mean age was 78 [75-88]. The American Society of Anesthesiologist's score was 1, 2, 3 and 4 in 10.5%, 60%, 29% and 0.5% of patients respectively. The mean tumor size was 4.6 cm. Indication of PN was elective in 122 (65%) patients and imperative in 52 patients (28%). The median length of surgery was 150(± 60) minutes, and the median estimated blood loss 200 ml. The mean glomerular filtration rate was 71.5 ml/minute preoperatively, and 62 ml/min three months after surgery. The severe complications (Clavien III-V) rate was 6.2%. On multivariate analysis, the robotic-assisted procedure was an independent protective factor of medical postoperative complications (Odds Ration (OR) = 0.31 [0.12-0.80], p = 0.01). It was adjusted for age and RENAL score, robotic-assisted surgery (OR = 0.22 [0.06-0.79], p = 0.02), and tumor size (OR = 1.13 [1.02-1.26], p = 0.01), but the patients age did not forecast surgical complications. Partial nephrectomy can be performed safely in elderly patients with an acceptable morbidity, and should be considered as a viable treatment option. Robotic assistance is an independent protective factor of postoperative complications., (© 2021. The Author(s).)

Purpose: We evaluated the feasibility and outcomes of immediate preoperative renal artery embolization (IPRAE) before complex nephrectomy for locally advanced RCC ± inferior vena cava thrombus (IVCT)., Methods: A comparative retrospective (2007-2017) multicenter study which included 145 patients with locally advanced RCC ± IVCT: 99 radical nephrectomies vs. 46 radical nephrectomies with IPRAE identified in the prospective UroCCR national database (CNIL DR 2013-206; NCT03293563). IPRAE was performed under local anesthesia the day of nephrectomy (< 4 h prior to nephrectomy). The primary endpoint was peroperative blood loss (mL). Secondary outcomes were: tolerance of embolization (pain visual scale), success rate of IPRAE defined by complete devascularization of the kidney, perioperative complications according to Clavien score and postoperative GFR., Results: The baseline characteristics of IPRAE and the control groups were similar. Tumor staging was 14% T2b, 41% T3a, 27% T3b, 13% T3c, 6% T4. The success rate of IPRAE was 98%. Median artery embolizated per patient was 2 (Agochukwu and Shuch in World J Urol 32:581-589, 2014; Marshall et al. in J Urol 139:1166-1172, 1988; Yap et al. in BJU Int 110:1283-1288, 2012;Gill et al. in J Urol. 194:929-938, 2015; Wang et al. in Eur Urol 69:1112-1119, 2016). No severe complications occurred after IPRAE. Postembolization syndrome was reported in 7% (Clavien I-II). Mean peroperative blood losses in the IPRAE and control groups were: 726 ± 118 ml and 1083 ± 114 ml (P = 0.03). In a multivariate analysis that included: age, Karnofsky index, IPRAE (yes vs. no), IVCT (yes vs. no), tumor size and synchronous metastasis, no IPRAE and IVCT were significantly associated with increased peroperative bleeding., Conclusion: IPRAE before nephrectomy for locally advanced and/or IVCT tumors was well tolerated, was associated with lower peroperative bleeding and did not increase the incidence or severity of postoperative complications.

Objective: To define guidelines for the management of renal cell carcinoma of the native kidney (NKRCC) in kidney transplant (KTx) recipients and renal cell carcinoma (RCC) in end-stage renal disease (ESRD) patients candidates for renal transplantation., Method: A review of the literature following a systematic approach (Medline) was conducted by the CTAFU to report renal cell carcinoma epidemiology, screening, diagnosis and management in KTx candidates and recipients. References were assessed according to a predefined process to propose recommendations with the corresponding levels of evidence., Results: ESRD patients are at higher risk of RCC with a standardized incidence ratio of approximately 4,5 as compared with general population. NKRCC tumors occur in 1 to 3 % of KTx recipients with a 10 to 15-fold increased risk as compared with general population, especially in patients with acquired multicystic kidney disease. Most authors suggest yearly monitoring of the native kidneys using ultrasound imaging. Radical nephrectomy (either open or laparoscopic approach) is the preferred treatment of NKRCC in KTx recipients and RCC in ESRD. Surveillance in a valid option in small or cystic renal masses. In the localized setting, change in immunosuppressive therapy is not recommended besides perioperative avoidance of mTOR inhibitor to limit morbidity. CTAFU does not recommend a mandatory waiting time after nephrectomy for RCC in ESRD patients candidates for renal tranplantation when tumor stage

Objective: To propose recommendations for the management of renal cell carcinomas (RCC) of the renal transplant., Method: Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU to evaluate prevalence, diagnosis and management of RCC arousing in the renal transplant. References were assessed according to a predefined process to propose recommendations with levels of evidence., Results: Renal cell carcinomas of the renal transplant affect approximately 0.2% of recipients. Mostly asymptomatic, these tumors are mainly diagnosed on a routine imaging of the renal transplant. Predominant pathology is clear cell carcinomas but papillary carcinomas are more frequent than in general population (up to 40-50%). RCC of the renal transplant is often localized, of low stage and low grade. According to tumor characteristics and renal function, preferred treatment is radical (transplantectomy) or nephron sparing through partial nephrectomy (open or minimally invasive approach) or thermoablation after percutaneous biopsy. Although no robust data support a switch of immunosuppressive regimen, some authors suggest to favor the use of mTOR inhibitors. CTAFU does not recommend a mandatory waiting time after transplantectomy for RCC in candidates for a subsequent renal tranplantation when tumor stage

Laparoscopic Partial Nephrectomy (LPN) after intra-arterial Embolization of renal tumors (LPNE) in a hybrid operating room allows renal tumor enucleation without dissection and clamping of the renal pedicle. The purpose was to assess the potential negative impact of embolization on the renal function. This prospective monocentric study included all patients treated with LPNE between May 2015 and June 2019. Clinical data was collected and incorporated into the UroCCR database (NCT03293563). Glomerular Filtration Rate (GFR) and Computed Tomography Renal Volume (CTRV) were compared before and after 6 months following LPNE. The mean post-operative GFR was 86.6 mL/min (SD 22.9). The mean GFR loss was 9.4% (SD 15.1) and the median renal parenchyma loss was 21 mL (SD 20.6). Using a threshold of 25% GFR loss, age was the only significant predictive factor of renal function impairment according to bivariate (59.5 vs 69.3 years, p = 0.017) and multivariable analysis (OR 1.075, CI 1-1.2], p = 0.05). Significant renal function impairment was not correlated with the renal parenchymal volume loss (OR 0.987, CI [0.95-1.02], p = 0.435). Renal function impairment after LPNE seems to be comparable to other techniques of partial nephrectomy.

Objective: - To update the French guidelines on kidney cancer., Methods: - A systematic review of the literature between 2015 and 2020 was performed. The most relevant articles regarding the diagnosis, the classification, surgical treatment, medical treatment and follow-up of kidney cancer were retrieved and included in the new guidelines. The guidelines were updated with corresponding levels of evidence., Results: - Thoraco-abdominal CT scan with injection is the best radiological exam for the diagnosis of kidney cancer. MRI and contrast ultra-sound can be useful in some cases. Percutaneous biopsy is recommended when histological results will affect clinical decision. Renal tumours must be classified according to pTNM 2017 classification and ISUP grade. Metastatic kidney cancers must be classified according to IMDC criteria. Partial nephrectomy is the recommended treatment for T1a tumours and can be done through an open, laparoscopic or robotic access. T1b tumours can be treated by partial or total nephrectomy according to tumour complexity. Radical nephrectomy is the recommended treatment of advanced localized tumours. There is no recommended adjuvant treatment. In metastatic patients: cyto-reductive nephrectomy can be offered in case of good prognosis; medical treatment must be counseled first in case of intermediate or bad prognosis. Surgical or local treatment of metastases should be considered in case of solitary lesion or oligo-metastases. First line recommended drugs in metastatic patients include the associations axitinib/pembrolizumab and nivolumab/ipilimumab. Cystic tumours must be classified according to Bosniak Classification. Surgical excision should be offered to patients with Bosniak III and IV lesions. It is recommended to follow patients clinically and with imaging according to tumour aggressiveness., Conclusion: - These updated recommendations should assist French speaking urologists for their management of kidney cancers., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Introduction: Bourneville's tuberous sclerosis or Tuberous Sclerosis Complex (TSC) is an autosomal dominant hereditary phakomatosis associated with angiomyolipomas (AML) of the kidney. The aim of this study was to identify the prevalence of TSC in patients diagnosed and cared for AML in our department of urology., Materials and Methods: All the patients with AML were included between March 2009 and June 2016 in a French university hospital. Each patient was reviewed in consultation with a clinical examination and imaging. Specific clinical criteria were used to refer patients to genetic analysis. Patients with a high TSC probability had a genetic analysis to search TSC1 and TSC2 genes mutations., Results: In all, 28 patients were included and 3 (11%) were diagnosed TSC. The median age of the patients was 62 years (36-82 years). The most frequent clinical criteria were facial angiofibromas in 7 patients (25%). Among the 8 patients (29%) with evocative clinical criteria, a mutation of the TSC1 and TSC2 genes was identified in 3 patients (11%) with a diagnosis of TSC made before the AML diagnosis., Conclusion: In this study, 8 patients (29%) presented clinical criteria suggestive of TSC, preferentially dermatological. The diagnosis was confirmed by screening TSC1 and TSC2 genes mutations in 3 patients (11%), nevertheless prevalence of TSC is most probably underestimated by the genetic mosaïcisme of this pathology., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Introduction: Partial nephrectomy (NP) after embolization of tumor vessels (NPESH) in a hybrid room combines embolization of tumor vessels and enucleation of the tumor under laparoscopy in the same operative time. The purpose of this study was to assess the impact of the use of NPESH in the management of patients treated with surgery for a localized kidney tumor., Material and Methods: Using the uroCCR database, we included all consecutive patients operated in a university hospital for localized kidney tumor. From 2011 to May 2015, patients were treated by Standard Partial Nephrectomy (NPS) Laparoscopic or Open and from May 2015 to May 2019 by NPESH. We evaluated characteristics of patients, tumors, perioperative data and complications. These data were compared by Student and Khi2 tests., Results: 87 NPS were performed during Period 1 and 137 NPS were performed during period 2. The ASA score of patients undergoing NPESH was higher than NPS (P<0.0001). The tumor complexity and median tumor size were similar in the two groups (P=0.852 and P=0.48). The complication rate for NPS and NPESH was 55.2% and 33.6% (P=0.002). There were less severe complications in the NEPSH group (P=0.012). The median length of stay was 8 and 4 days for the NPS and NPESH groups (P<0.0001). Positive surgical margins were 2 (2.3%) and 6 (4.6%) for the NPS and NPESH group (P=0.713)., Discussion: NPESH is an efficient technique compared to NPS. It seems to be an interesting alternative to limit renal ischemia, complication rate and length of stay for the management of localized kidney tumors., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Purpose: To improve the tumor localization during laparoscopic surgery, we describe an innovative technique involving superselective intra-arterial injection of blue dye in tumoral vessels to color the tumor before surgical enucleation. Materials and Methods: The dye injection was performed at the same time as superselective embolization, immediately before laparoscopic surgery in a hybrid operating room. We used this new treatment sequence on 50 consecutive patients. Results: The selective intra-arterial injection of an emulsion of blue dye and lipiodol was feasible in 46 (92%) cases and well tolerated, followed by superselective embolization of the tumor vessels with glue or coils. The tumor was easily localized during surgery due to the blue coloration. Tumor coloration was not associated with postoperative complication, especially allergic reaction or renal failure. Pathologic analysis of the tumor was not modified by the coloration and all tumors had negative surgical margins. Conclusions: The preoperative dye localization is a feasible, safe, and accurate procedure. This combined approach reduces the difficulty of surgery and increases patient safety.

Background: In a cadaveric model with healthy kidneys, it has recently been highlighted that a single renal segment could be supplied by one or more arterial branches originating from an artery supplying another segment., Objective: To demonstrate occurrences of anatomical variations of renal vascularization and to analyze vascularization of renal tumors., Design, Setting, and Participants: This prospective monocentric study included all patients treated for a renal tumor between May 2015 and June 2017 by laparoscopic partial nephrectomy after superselective tumor embolization in a hybrid operating room., Intervention: Three-dimensional renal and tumoral arteriography with cone-beam computed tomography scan was performed, coupled with preoperative cross-sectional imaging. This procedure provided an accurate vascular anatomical mapping of the kidney and allowed further analysis of tumor vascularization., Outcome Measurements and Statistical Analysis: Relation between anatomical variations of the vascularization and perioperative data was assessed. A χ 2 test or Fisher's test was used for qualitative variables, and a Student t test was used for quantitative variables., Results and Limitations: Out of the 60 patients included, only 25 (42%) presented a standard vascular subdivision. In 26 patients (43%), tumors were supplied by more than one branch and in 20 patients (33%), there was a branch supplying the tumor from another segment. In these cases of multiple or multi-segmental tumor vascularization, tumor size, operative duration, and duration of embolization were significantly higher than in the case of standard vascularization. These complex tumors were more often located at the upper pole of the kidney or at the junction of the anterior and posterior vascular territories of the kidney. Limitations of this study include the low number of patients and its monocentricity., Conclusions: This study confirms that renal vascularization frequently differs from Graves' reference model and that tumor vascularization can depend on several segmental branches. This vascular complexity explains surgical difficulties and must be taken into consideration when segmental arterial clamping is considered during partial nephrectomy., Patient Summary: We studied renal and tumor vascularization using three-dimensional preoperative arteriography data on tumor kidneys. We have shown that there is great variability in renal vascularization and that tumors can be vascularized branches that originate from an artery leading to another segment. This vascular complexity explains surgical difficulties and must be taken into consideration when segmental arterial clamping is considered during partial nephrectomy., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: Modalities of surveillance to detect recurrence after nephrectomy for localized or locally advanced renal tumor are not standardized. The aim was to assess the impact of surveillance scheme on oncological outcomes., Methods: Patients treated for localized or locally advanced renal tumor with total or partial nephrectomy between 2006 and 2010 in an academic institution were included retrospectively. According to the University of California Los Angeles Integrated Staging System (UISS) protocol, follow-up was considered adequate or not. Symptoms, location and number of lesions at recurrence diagnosis were collected. Recurrence-free, cancer-specific and overall survivals were estimated using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazards regression models were calculated to identify prognostic factors., Results: A total of 267 patients were included. Median follow-up was 72 months. Recurrence rate was 23.2% (62/267 patients). Recurrences were local (16%), single metastatic (23%), oligo-metastatic (15%) or multi-metastatic (46%). 72.6% of the recurrences occurred within the 3 years after surgery. No recurrence was diagnosed by chest X-ray or abdominal ultrasound. One hundred and twenty-one patients had inadequate follow-up. They had similar recurrence-free survival, cancer-specific survival and overall survival as patients with adequate follow-up. In multivariable analysis, the presence of multi-metastatic lesions was an independent prognostic factor of worse cancer-specific mortality after recurrence diagnosis (HR = 10.15, 95% CI: 2.29-44.82, p = 0.002)., Conclusion: Role of chest X-ray and abdominal ultrasound for the detection of recurrences is limited. Rigorous follow-up according to the UISS protocol does not improve oncological outcomes. Follow-up schedules with less frequent imaging should be discussed.

Objective: To evaluate the diagnostic accuracy of multidetector Computed Tomography (MDCT) in predicting T3a renal cell carcinoma (RCC). Materials and methods: Preoperative MDCT of 96 patients with 100 pathologically proven RCC were assessed by two radiologists focusing on the presence of peritumoral fat, sinus fat or venous invasion for cT3a staging. Nature of tumor margins and the presence of peritumoral neovessels were also evaluated, as the influence of perinephric soft-tissue stranding in the interpretation of peritumoral fat. Results: Sensitivity for the identification of peritumoral fat, sinus fat or renal vein invasion was 77%, 86% and 86%, and specificity was 72%, 88% and 97%, respectively. Sensitivity and specificity in the prediction of T3a tumors were 72% and 70% respectively ( κ score = 0.38 (0.29-0.47)). Among the 38 pT3 tumors, 6 (16%) were under-staged, and the neovessels and irregular tumor edge as secondary CT signs did not significantly increase the accuracy of the prediction of local invasion. Among the 62 confined tumors, 17 (27%) were over-staged as cT3 and among these 17 false positives cases, perinephric soft-tissue stranding was present in 14 cases. Conclusion: MDCT provides good results in detecting sinus fat, venous invasion and kidney-confined tumors, but evaluation of perinephric fat remains a difficult task, leading to reduced accuracy in T3a staging.

Objectives: To evaluate the prognostic role of the Bosniak classification on the long-term oncological outcomes of cystic renal cell carcinomas., Material and Method: In a national multicentric retrospective study, we included patients treated surgically for localized cystic RCC from 2000 to 2010. Patients with a follow-up of less than 4 years, benign tumors, and ablative treatments were excluded. The primary outcome was disease-free survival., Results: 152 patients met the inclusion criteria: Bosniak II (6%), III (53%), IV (41%), with a median follow-up of 61 (12-179) months. Characteristics of the population and the tumors were [median, (min-max)] age 57 (25-84) years old, tumor size 43 mm (20-280), RENAL score 7 (4-12), PADUA score 8 (5-14). Treatments were 55% partial nephrectomy, 45% radical nephrectomy, 74% open surgery, and 26% laparoscopy. In pathological report, cystic RCC were mainly of low grade (1-2, 77%) and low stage (pT1, 81%). The two main histological subtypes were conventional (56%) and papillary (23%) RCC. Staging at presentation and histological characteristics were similar between Bosniak III and IV, except for high grade which was more common in Bosniak IV (12 vs 36%, p < 0.01). The Bosniak classification was not predictive of the recurrence, as 5- and 10-year disease-free survival were similar in Bosniak III and IV (92% vs 92% and 84% vs 83%, p = 0.60)., Conclusion: The Bosniak classification is predictive of the risk of malignancy but not of the oncological prognosis. Regardless of the initial Bosniak categories, almost all cystic RCCs were of low stage/grade and had low long-term recurrence rate.

Background and Methods: Nephrectomy is the treatment for renal cell cancer from T1-4 tumors but remains at risk. To determine the thirty-day mortality rate after nephrectomy for cancer and to identify causes and risk factors of death in order to find clinical applications. From 2014 to 2017, we performed a retrospective multicentric analysis of prospectively collected data study involving the French network for research on kidney cancer (UroCCR). All patients who died after nephrectomy for cancer during the first thirty days were identified. Patients' characteristics, causes of death and morbidity and mortality reviews reports were analyzed for each death., Results and Limitations: In total, 2578 patients underwent nephrectomy and 35 deaths occurred. The thirty-day mortality rate was 1.4%. In univariate analysis, symptoms at diagnosis (P=0.006, OR=2.56 IC (1.3-5.03)), c stage superior to cT1 (P<0.0001, OR=6.13 IC (2.8-13.2)), cT stage superior to cT2 (P<0.0001, OR=8.8 IC (4.39-17.8)), nodal invasion (P<0.0001, OR=4.6 IC (1.9-10.7)), distant metastasis (P=0.001, OR=4.01 IC (1.7-8.9)), open surgery (P<0.0001, OR=0.272 IC (0.13-0.54)) and radical nephrectomy (P=0.007, OR=2.737 IC (1.3-5.7)) were risk factors of thirty-day mortality. In a multivariable model, only cT stage superior to T2 (P=0.015, OR=3.55 IC (1.27-10.01)) was a risk factor of thirty-day mortality. The main cause of postoperative death was pulmonary (n=15; 43%). The second cause was postoperative digestive sepsis for 7 patients (20%). Only 2 morbidity and mortality reviews had been done for the 35 deaths. Limitations are related to the thirty-day mortality criteria and descriptive study design., Conclusions: Symptomatic patients, stage cTNM and type and techniques of surgery are determinants of thirty-day mortality after nephrectomy for cancer. The first cause of postoperative death is pulmonary. Morbidity and mortality reviews should be considered to better understand causes of death and to reduce early mortality after nephrectomy for cancer., Level of Evidence: 4., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)