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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.

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.)

Introduction: Kidney transplant (KT) recipients have a four-times higher risk of renal malignancies compared to general population. As these patients frequently harbor bilateral or multifocal tumors, the management of renal masses is still under debate., Objective: To explore the current management of the native kidney masses in KT patients., Acquisition of Evidence: We performed a literature search on MEDLINE/PubMed database. A number of 34 studies were included in the present review., Synthesis of Evidence: In frail patients with renal masses below 3 cm, active surveillance is a feasible alternative. Nephron-sparing surgery is not justified for masses in the native kidney. Radical nephrectomy is the standard treatment for post-transplant renal tumors of the native kidneys in KT recipients, with laparoscopic techniques leading to significantly less perioperative complication rates as compared to the open approach. Concurrent bilateral native nephrectomy at the time of transplantation can be considered in patients with renal mass and polycystic kidney disease, especially if no residual urinary output is present. Patients with localized disease and successful radical nephrectomy do not require immunosuppression adjustment. In metastatic cases, mTOR agents can ensure efficient antitumoral response, while maintaining proper immunosuppression in order to protect the graft., Conclusions: Post-transplant renal cancer of the native kidneys is a frequent occurrence. Radical nephrectomy is most frequently performed for localized renal masses. A standardized and widely-approved screening strategy for malignancies of native renal units is yet to be implemented., (Copyright © 2023 The Author(s). Published by Elsevier España, S.L.U. All rights reserved.)

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.)

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.)

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: 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.)

Objective: To analyze de novo graft carcinoma characteristics from our updated national multicentric retrospective cohort., Methods: Thirty-two transplant centers have retrospectively completed the database. This database concerns all kidney graft tumors including urothelial, and others type but excludes renal lymphomas over 31 years., Results: One hundred and fifty twokidney graft carcinomas were diagnosed in functional grafts. Among them 130 tumors were Renal Cell Carcinomas. The calculated incidence was 0.18%. Median age of the allograft at diagnosis was 45.4 years old. The median time between transplantation and diagnosis was 147.1 months. 60 tumors were papillary carcinomas and 64 were clear cell carcinomas. Median tumor size was 25 mm. 18, 64, 21 and 1 tumors were respectively Fuhrman grade 1, 2, 3 and 4. Nephron sparing surgery (NSS) was performed on 68 (52.3%) recipients. Ablative therapy was performed in 23 cases (17.7%). Specific survival rate was 96.8%., Conclusion: This study confirmed that renal graft carcinomas are a different entity: with a younger age of diagnosis; a lower stage at diagnosis; a higher incidence of papillary subtypes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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).)

The oncological impact of positive surgical margins (PSM) after robot-assisted partial nephrectomy (RAPN) is still under debate. We compared PSM and Negative Surgical Margins (NSM) in terms of recurrence-free survival (RFS), metastasis-free survival (MFS) and overall survival (OS) after RAPN, and we identified predictive factors of PSM. Multi-institutional study using the UroCCR database, which prospectively included 2166 RAPN between April 2010 and February 2021 (CNIL DR 2013-206; NCT03293563). Two groups were retrospectively compared: PSM versus NSM. Prognostic factors were assessed using Kaplan-Meyer curves with log-Rank test, cox hazard proportional risk model and logistic regression after univariate comparison. 136 patients had PSM (6.3%) and 2030 (93.7%) had NSM. During a median follow-up of 19 (9-36) months after RAPN, 160 (7.4%) recurrences were reported. Kaplan-Meier curves and analysis suggested that RFS, MFS and OS were not affected by a PSM (p = 0.68; 0.71; 0.88, respectively). In multivariate analysis predictors of PSM were a lower RENAL score (p = 0.001), longer warm ischemia time (WIT) (p = 0.003) and Chromophobe Renal Cell Carcinoma (chrRCC) (p = 0.043). This study found no impact of PSM on RFS, MFS or OS, and predictors of PSM were the RENAL score, WIT and chrRCC., (© 2022. The Author(s).)

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.)

Objectives: To report the outcomes and feasibility of active surveillance (AS) of biopsy-proven renal oncocytomas., Methods: Multicentric retrospective study (2010-2016) in 6 academic centers that included patients with biopsy-proven renal oncocytomas who were allocated to AS (imperative or elective indication) with a follow-up ≥1 year. Imaging was performed at least once a year, by CT-scan or ultrasound or MRI. Conversion to active treatment (surgical excision or ablative treatment) was at the discretion of the urologist. The primary endpoint was renal tumor growth (cm/year). Secondary outcomes included accuracy of biopsy, incidence, and reason to change AS to active treatment., Results: Eighty-nine patients were included: Median age 67 years (26-89) and median tumor size 26 mm [15-90] on diagnosis. During a mean follow-up of 43 months'' (median 36 [12-180]), mean tumor growth was 0.24 cm/year. No predictive factors (demographical, radiological or histologic) of tumor growth could be identified. Conversion from AS to active treatment occurred in 24 patients (27%) (13 surgical excisions, 11 ablative procedures), in a median time of 45 (12-76) months'' after diagnosis. Tumor growth was the main indication to convert AS to active treatment (58%) with 8% of the patients opting to discontinue AS. No patient had metastatic progression nor disease-specific death. The correlation between biopsy and surgical specimen was 92%., Conclusion: Active surveillance for biopsy-proven renal oncocytomas was oncologically safe and patient adherence was high. No predictive factor for tumor growth could be identified but the tumor growth rate was low, and biopsy efficacy was high., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To evaluate the long-term oncological and functional results of the ablative treatment of T1a kidney malignancies by percutaneous radiofrequency (RF)., Materials and Methods: Monocentric retrospective study including all patients treated for renal cell carcinoma (RCC) T1a by radiofrequency, in our center, from 2005 to 2009. All patients had a tumor biopsy before treatment. The primary endpoint was local recurrence. A total of 44 RCCs in 41 consecutive patients were treated (1 patient had 3 synchronous tumors and 1 patient had 2 tumors). There were 26 clear cell RCCs, 13 papillary RCCs and 5 chromophobe RCCs. The median age at diagnosis was 70 years [48-82]. The median American Society of Anesthesiologists (ASA) score was 2 [1-3] and the median glomerular filtration rate (GFR) was 64mL/min [26-109]. Furhman grade was defined for 39 tumors (Clear cell RCC and papillary RCC), of which 82% were grade 1-2. The median tumor size was 20mm [11-40], and the median RENAL score was 4 [4-6]. Complications were assessed according to the Clavien-Dindo classification. Overall survival, recurrence-free survival and metastasis-free survival were calculated using the Kaplan-Meier method., Results: Median follow-up was 90.5 months [17.8-145.3]. Three (7%) local recurrences were reported within a median of 26 months [12-93]. All were treated by a 2nd RF. The overall 10-year survival was 70% (95% CI [56-85]). The 10-year recurrence-free survival was 72% (95% CI [57-88]). The 10-year metastasis-free survival was 87% (95% CI [74-97]). The median GFR on the date of the last news was 51mL/min [16-98] (P=0.05). Post-RFA complications consisted in 5 (11.3%) Clavien-Dindo 1-2 complications. No high grade (Clavien ≥3)., Conclusion: Percutaneous radiofrequency for RCC T1a is an alternative. It appears to be safe with low morbidity, satisfaying long-term oncological and functional results, but a risk of reprocessing of 7%., Level of Evidence: 3., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

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 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: Oncocytomas are primitive kidney tumours, considered benign but their evolution is not fully established. The local progression is generally admitted but few data explain what makes a oncocytoma to grow more or less quickly. The objective of our study is to analyse the evolution of followed renal oncocytomas after histologic confirmation and to identify factors that can influence their growth., Material and Methods: This is a retrospective study in two centers (North Hospital and Hospital of the Conception of Marseille). All patients with renal oncocytoma diagnosed with percutaneous biopsy from September 2010 to April 2016 and followed for more than one year were included. Epidemiological, histological, and morphological data were collected at diagnosis, during follow-up and in case of strategy change (intervention). Statistical analysis of factors influencing oncocytomes growth was based on the Pearson correlation test., Results: Fifty-three patients were included. The median age for diagnosis was 65 years [39-85]. The sex ratio H/F was 6/5. The median follow-up was 34 months [12-180]. The average diagnosis size was 29 mm [12-90]. Thirteen patients (25%) were treated secondarily, including 70% by conservative treatment. The average growth was 0.25 (±0.23) cm/yr. The patients treated were younger and had a higher growth rate than the untreated (0.48±0.23cm/yr versus 0.18±0.18cm/yr, P<0,001). According to Pearson's analysis, there was a positive linear relationship (R=0.27, P=0.047) between velocity and initial size and a negative linear relationship (ρ=-0.44, P<0.001) between velocity and age at diagnosis. So tumor growth was faster if the patients were young and the tumor voluminous at diagnosis., Discussion: Rapid growth often leads to a cessation of surveillance in favour of an intervention strategy. For young patients, conservative treatment (partiel nephrectomy or ablative treatment) in the medium term is likely to be preferred, but for elderly patients or with important comorbidities follow-up is an alternative to an invasive attitude., Level of Evidence: 3., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Aim: Characteristics of renal carcinoma arising in non-functional graft in renal transplant recipients (RTR) are unknown. We studied a large national retrospective cohort to analyze circumstances of diagnosis, treatment and outcome compared to the literature., Methods: Study included all RTR presenting with kidney graft tumors irrespective of the histology, except those with lymphoma and including those tumors arising in non-functional renal graft. Between January 1988 and December 2018, 56,806 patients had renal transplantation in the 32 centers participating in this study. Among this cohort, 18 renal graft tumors were diagnosed in non-functional grafts., Results: The median patient age at the time of diagnosis was 42.1 years (31.7-51.3). Median age of kidney grafts at the time of diagnosis was 56.4 (23.2-63.4). Eight (44.4%) tumors were discovered fortuitously on renal graft histologic analysis. Fourteen tumors (77.8%) were papillary carcinomas. Two patients had clear cell carcinomas and one patient had a pTa high-grade multifocal urothelial carcinoma in the graft of the upper tract with an in situ carcinoma., Conclusion: Renal carcinomas in non-functional grafts are rare entities and most of them are diagnosed fortuitously. Despite the fact that these tumors are small, low grade and with a good prognosis, regular monitoring of non-functional grafts should be performed with at least an annual ultrasonography.

Objective: To evaluate the renal function outcomes after selective trans-arterial embolization (SAE) of iatrogenic vascular lesions (IVL), including pseudoaneurysm and arteriovenous fistula, following partial nephrectomy (PN)., Materials and Methods: A multi-institutional study was conducted including consecutive patients who underwent PN between January 2009 and March 2019. Two surgical approaches were used: open and robot-assisted PN. Patients with SAE were identified and matched (1:2) with patients without IVL. The matching criteria were age, gender, Charlson score, creatinine clearance, RENAL score, and tumor size. The primary outcome was the evolution of global renal function at 6-months postoperatively., Results: A total of 493 consecutive PN (360 open PN and 133 robot-assisted PN) were included. IVL occurred in 17 cases (3.4%) without statistical difference according to the surgical approach (P = .78). Patients from embolization group were matched to 34 cases without postoperative IVL. Groups were comparable concerning clinical, tumor and surgical characteristics. The clinical success of SAE, defined as the absence of recourse to a second embolization or a total nephrectomy, was obtained in 16 (94.1%) cases. No minor or major complications were reported after SAE. The preoperative estimated glomerular filtration rate (eGFR) was similar between control group (93 [85-102] ml/min) and embolization group (95 [83-102] ml/min) (P = .99). Median (IQR) eGFR between control group (87 [72-95] ml/min) and embolization group (83 [76-93] ml/min) at a follow-up of 6 months showed no significant difference (P = .73)., Conclusion: IVL are rare complications of PN. SAE is an effective and minimally invasive management tool, with no deleterious effect on global renal function., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Urinary tract infection (UTI) is a common complication after flexible ureteroscopy (fURS) despite technical precautions to avoid infectious complications. The aim was to investigate incidence and predictive risk factors of UTI following fURS procedure., Patients and Methods: We conducted a retrospective study including consecutive fURS performed in our center from January 2015 to March 2019. The indications were: nephrolithiasis management and diagnosis and conservative treatment of upper urinary tract urothelial carcinomas (UTUC). Since 2015, we had technical precautions to avoid postoperative infectious complications: centralized collection of preoperative urine cultures which are examined daily by an urologist and a service provider, systematic use of ureteral access sheath and application of standardized antibiotic prophylaxis measures. The primary endpoint was occurrence of UTI within 15 days following fURS., Results: Six hundred and four fURS were included for nephrolithiasis (n = 462) and UTUC management (n = 142). The median (IQR) age in the study cohort was 61(48-68) years, 268 female patients were included (44.4%), the median (IQR) Charlson score was 2(1-4) and single-use fURS were used in 186 cases (30.8%). Postoperative UTI occurred in 41 cases (6.7%). In multivariate analysis, female gender (OR 2.20 [1.02-5.02], p = 0.04), UTI within the last 6 months (OR 2.34 [1.12-5.11], p = 0.02), preoperative polymicrobial urine culture (OR 4.53 [1.99-10.56], p < 0.001) and increased operative time (OR 1.02 [1.002-1.031], p = 0.02) remain associated with postoperative UTI., Conclusions: In a large cohort study, female gender, prior UTI, increased operative time and preoperative polymicrobial urine culture were associated with the occurrence of postoperative UTI. Limiting operative time and improving our knowledge of polymicrobial urine cultures could reduce the infectious risk.

Objective: To calculate the incidence of renal graft urothelial carcinoma in renal transplant recipients in a national large retrospective cohort and to analyze circumstances of diagnosis, treatment and outcome., Material and Methods: We conducted a national retrospective, multicenter study. Thirty two transplant centers were asked to report its cases of kidney graft tumors and the number of kidney transplantations performed since the beginning of their transplantation activity., Results: Between January 1988 and December 2018, 56,806 patients were transplanted in the 32 centers participating in this study. Among this cohort, 107 renal graft tumors (excluding lymphoma) were diagnosed among them 11 renal transplant recipients were diagnosed with an urothelial carcinoma in the kidney graft. The calculated incidence was 0.019%. The median patient age at the time of diagnosis was 56.7 years (49.8-60.9) and 51.4 years (47-55.7) at the time of transplantation. The median time between transplantation and diagnosis was 66.6 months (14.3-97). Before treatment, 3 patients had graft tumor biopsies revealing urothelial carcinomas, 3 patients had endoscopic retrograde uretero-pyelography showing lacunary images. Two patients had a diagnostic flexible ureteroscopy with biopsies. Total nephrectomy was performed in all cases., Conclusion: Even though occurring in the context of immune suppression, most of these tumors seemed to have a relatively good prognosis. With regards to functional outcomes histological diagnosis should always be sought for before radical treatment of these tumors. Treatment should be a transplant nephrectomy including all the ureter with a bladder cuff to ensure optimal carcinologic control., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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.

Context: Kidney transplantation is the best treatment for patients with end-stage renal disease. Incidence of small renal masses (SRMs), which most frequently are renal cell carcinomas (RCCs), is highest in patients aged >60 yr. The increasing age of donors can lead to the diagnosis of a higher number of SRMs when assessing the patient for transplantation, and so can theoretically decrease the number of kidneys suitable for transplantation. Aiming to increase the pool of kidneys suitable for transplantation, a number of studies have reported their experience using kidneys with SRMs for transplantation., Objective: To systematically review all available evidence on the effectiveness and harm of using kidneys with SRMs as a source of transplantation., Evidence Acquisition: A computerized bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting outcomes of adult renal transplantation using kidneys with SRMs., Evidence Synthesis: Nineteen studies enrolling 109 patients were included and synthesized narratively. The mean recipient age was 44.2 yr, and kidneys used were retrieved from living donors in 86% (94/109) of cases. Tumor excision was performed ex vivo in all cases except for two. The vast majority of excised tumors were RCCs (88/109 patients), and clear-cell subtype was most common. The mean tumor size was 2cm (range 0.5-6.0cm) and tumor grade was G1-G2 in 93% (75/81) of patients. With a mean follow-up of 39.9 mo, overall survival rates at 1, 3, and 5 yr were 97.7%, 95.4%, and 92%, respectively, and the mean graft survival rates 99.2%, 95%, and 95.6%, respectively. Only one local relapse occurred 9 yr after transplantation, which was managed conservatively. Functional outcomes, although infrequently reported, appear to be similar to those of conventional transplants, with 1.6% of these patients needing reoperation., Conclusions: The current literature, although with low-level evidence, suggests that kidneys with excised SRMs are an acceptable source of transplantation without compromising oncological outcomes and with similar functional outcomes to other donor kidneys., Patient Summary: Renal transplantation using a kidney with a small renal mass does not appear to increase the risk of cancer recurrence and can be a good option for selected patients after appropriate counseling and allocation., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.004. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.004. That newer version of the text should be used when citing the article., (Copyright © 2018. Published by Elsevier Masson SAS.)

Background: The neutrophil-lymphocyte ratio (NLR) is a biological marker of inflammation with a significant prognostic value in the field of oncology., Aim: In this review, we discuss the prognostic value of the NLR in renal cell carcinoma (RCC)., Material and Method: We conducted a literature review of the PubMed database in August 2016. Initial research identified 31 publications. Following full-text screening, 15 studies were finally included: 7 studies concerning metastatic or locally advanced renal cancer, 6 studies dealing with localized renal cancer, 2 articles evaluating the NLR in renal cancer whatever the status of the disease (metastatic or localized)., Results: For localized RCC, an NLR o 3 was predictive of a reduced risk of recurrence (hazard ratio ¼ 1.63 [1.15, 2.29]). The prognostic value of the NLR was stronger for metastatic or locally advanced RCC. An NLR o 3 predicted increased overall survival (hazard ratio ¼ 1.55 [1.36, 1.76]), progression-free survivals (hazard ratio ¼ 3.19 [2.23, 4.57]), and a response to systemic treatment., Conclusion: In current practice, the NLR is a simple and inexpensive prognostic factor with potential improvement in the prognostic performance of nomograms used in renal oncology., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To compare partial nephrectomy (PN) and percutaneous ablative therapy (AT) for renal tumor in imperative indication of nephron-sparing technique (NST)., Materials and Methods: Between 2000 and 2015, 284 consecutive patients with a kidney tumor in an imperative indication of NST were retrospectively included in a multicenter study. PN [open (n = 146), laparoscopic (n = 9), or robotic approach (n = 17)] and AT [radiofrequency ablation (n = 104) or cryoablation (n = 8)] were performed for solitary kidney (n = 146), bilateral tumor (n = 78), or chronic kidney disease (CKD) (n = 60)., Results: Patients in the PN group had larger tumors and a higher RENAL score. There were no differences between the two groups with respect to age, reasons for imperative indication, and preoperative eGFR. Patients in the AT group had a higher ASA and CCI. PN had worse outcomes than AT in terms of transfusion rate, length of stay, and complication rate. Local radiological recurrence-free survival was better for PN, but metastatic recurrence was similar. Percentage of eGFR decrease was similar in the two groups. Temporary or permanent dialysis was not significantly different. On multivariate analysis, PN and AT had a similar eGFR change when adjusted for tumor complexity, reason of imperative indication and CCI., Conclusion: In imperative indication of nephron-sparing treatment for a kidney tumor, either PN or AT can be proposed. PN offers the ability to manage larger and more complex tumors while providing a better local control and a similar renal function loss.

The previous guidelines from the Cancer Committee of the Association Française d'Urologie were published in 2013. We wanted this new version to be simple, clear and straightforward. All significant recent publications on kidney cancer have been included. The main changes compared to 2013 are the following: © 2016 Elsevier Masson SAS. All rights reserved., (© 2016 Elsevier Masson SAS. Tous droits réservés.)

Renal epithelioid angiomyolipomas (ReAML) are rare tumors (identified in less than 0,1 per thousand in general population) and represent 8% of operated angiomolipomas (AML). The diagnostic is histological, with an epithelioid cell component among the typical AML cells. ReAML are tumors derived from perivascular epithelioid cells (PEComa). There are benign PEComas, potentially aggressive PEComas and malignant PEComas. Most malignant PEComas are ReAML. There are two ReAML clinical entities, sporadic or associated to Tuberous Sclerosis Complex (TSC). ReAML are unique, localized and sporadic solid tumors of the kidney of variable size that can be revealed as classical AML with local symptoms or a complication (hemorrhage). Revelation mode is mostly radiologic. ReAML are fat-poor on CT-scan. They can be misdiagnosed with renal cell carcinoma (RCC). (One third of ReAML are malignant with a locoregional, nodal or metastatic evolution that can lead to death. ReAML treatments are multimodal depending of histology, clinical-radiological entity, evolution and the patient. Partial nephrectomy or follow-up are the benign entity treatment. Radical nephrectomy eventually followed by doxorubicine or rapamycine treatments are recommended for potentially aggressive and malignant entities.