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Background: Cytoreductive nephrectomy (CN) plays an important role in the treatment of a subgroup of metastatic renal cell carcinoma (mRCC) patients., Objective: We aimed to evaluate morbidity associated with this procedure and identify potential predictors thereof to aid patient selection for this procedure and potentially improve patient outcomes., Design, Setting, and Participants: Data from 736 mRCC patients undergoing CN at 14 institutions were retrospectively recorded in the Registry for Metastatic RCC (REMARCC)., Outcome Measurements and Statistical Analysis: Logistic regression analysis was used to identify predictors for intraoperative, any-grade (AGCs), low-grade, and high-grade (HGCs) postoperative complications (according to the Clavien-Dindo classification) as well as 30-d readmission rates., Results and Limitations: Intraoperative complications were observed in 69 patients (10.9%). Thrombectomy (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.08-1.75, p = 0.009) and adjacent organ removal (OR 2.7, 95% CI 1.38-5.30) were significant predictors of intraoperative complications at multivariable analysis. Two hundred seventeen patients (29.5%) encountered AGCs, while 45 (6.1%) encountered an HGC, of whom 10 (1.4%) died. Twenty-four (3.3%) patients had multiple postoperative complications. Estimated blood loss (EBL; OR 1.49, 95% CI 1.08-2.05, p = 0.01) was a significant predictor of AGCs at multivariable analysis. CN case load (OR 0.13, 95% CI 0.03-0.59, p = 0.009) and EBL (OR 2.93, 95% CI 1.20-7.15, p = 0.02) were significant predictors solely for HGCs at multivariable analysis. Forty-one patients (11.5%) were readmitted within 30 d of surgery. No significant predictors were identified. Results were confirmed in a subanalysis focusing solely on patients treated in the contemporary targeted therapy era., Conclusions: Morbidity associated with CN is not negligible. Predictors of high-grade postoperative morbidity are predominantly indicators of complex surgery. EBL is a strong predictor of postoperative complications. CN case load correlates with lower high-grade morbidity and highlights the benefit of centralization of complex surgery. However, risks and benefits should be balanced when considering CN in mRCC patients., Patient Summary: We studied patients with metastatic renal cancer to evaluate the outcomes associated with the surgical removal of the primary kidney tumor. We found that this procedure is often complex and adverse events are not uncommon. High intraoperative blood loss and a small number of cases performed at the treating center are associated with a higher rate of postoperative complications., (Copyright © 2020. Published by Elsevier B.V.)

Purpose: Because the prognostic impact of the clinical and pathological features on cancer-specific survival (CSS) and overall survival (OS) in patients with papillary renal cell carcinoma (papRCC) is still controversial, we want to assess the impact of clinicopathological features, including Fuhrman grade and age, on survival in surgically treated papRCC patients in a large multi-institutional series., Methods: We established a comprehensive multi-institutional database of surgically treated papRCC patients. Histopathological data collected from 2189 patients with papRCC after radical nephrectomy or nephron-sparing surgery were pooled from 18 centres in Europe and North America. OS and CSS probabilities were estimated using the Kaplan-Meier method. Multivariable competing risks analyses were used to assess the impact of Fuhrman grade (FG1-FG4) and age groups (<50 years, 50-75 years, >75 years) on cancer-specific mortality (CSM)., Results: CSS and OS rates for patients were 89 and 81% at 3 years, 86 and 75% at 5 years and 78 and 41% at 10 years after surgery, respectively. CSM differed significantly between FG 3 (hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.17-8.22; p < 0.001) and FG 4 (HR 8.93, 95% CI 4.25-18.79; p < 0.001) in comparison to FG 1. CSM was significantly worse in patients aged >75 (HR 2.85, 95% CI 2.06-3.95; p < 0.001) compared to <50 years., Conclusions: FG is a strong prognostic factor for CSS in papRCC patients. In addition, patients older than 75 have worse CSM than patients younger than 50 years. These findings should be considered for clinical decision making.

Objective The aims of this study were to identify clinical, intraoperative and pathological prognostic factors for predicting extraurothelial recurrence and cancer-specific survival (CSS) in patients with upper urinary tract urothelial carcinoma (UTUC) who had undergone laparoscopic radical nephroureterectomy (LRNU), and to investigate the site-specific patterns of recurrence and the associated outcomes. Materials and methods A retrospective revision was undertaken of 117 consecutive patients who had undergone transperitoneal LRNU for UTUC between 2007 and 2012. Univariate and multivariate Cox regression analyses were used to identify prognostic factors and Kaplan-Meier was used to estimate CSS. Results With a median follow-up of 20 months, 36 patients (30%) developed extraurothelial recurrence (local and/or distant). In the multivariate analysis, entering the urinary tract during LRNU was related to local recurrence (p = 0.04), management of the distal ureter to CSS (p = 0.003), pathological stage and positive margins to local (p = 0.001, p = 0.013), distant (p = 0.028, p = 0.009) and global recurrence (p = 0.05, p = 0.012) and CSS (p = 0.011, p = 0.042), and multifocality to distant recurrence (p = 0.024). Median time to recurrence was 11.4 months after LRNU. Of 36 patients with progression, 23 (64%) had simultaneous local and distant recurrence and eight had atypical metastases: two port-site metastases, five peritoneal, two subcutaneous and two abdominal wall implants. The 5 year CSS was 61% for all patients with UTUC and 9% for those with recurrence. Conclusions Intraoperative events could have a negative impact on the oncological outcomes of patients with UTUC treated with LRNU. The use of laparoscopy for advanced UTUC may be related to atypical ways of spreading.

Objective: To describe the temporal trends in surgical techniques for the management of renal masses at a single Spanish academic institution and identify factors associated with partial nephrectomy (PN) decision., Materials and Methods: A total of 646 patients were treated by surgery for clinically localised renal masses from January 2004 to December 2012 at a tertiary referral center. Surgical techniques included open radical nephrectomy (RN), open PN, laparoscopic RN, and laparoscopic PN. Descriptive statistics were used to compare baseline characteristics and proportions of patients treated by different surgical techniques. Annual trends in the proportion of procedures performed were determined. Adjusted odds ratios (OR) and 95% confidence intervals were calculated to evaluate clinical variables predictive of PN., Results: During the 9-year study period, the proportion of PN relative to RN increased from 21% to 55%. With regard to surgical approach, open procedures for both RN and PN decreased gradually in favor of minimally invasive approaches (83% in 2004 to 4% in 2011-2012). While median tumor size did not significantly change over the study period, laparoscopic PN became the most commonly performed kidney procedure in 2011-2012 (49% of all procedures). Clinical variables independently predictive of partial nephrectomy were ASA score, baseline renal function and tumor size (all P<.05)., Conclusions: At our academic institution, temporal trends in the management of renal masses have established PN as the most common surgical option. Although PN was increasingly used over the study period, a parallel increase in minimally invasive approaches for RN and PN was seen., (Copyright © 2015 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: Our aim was to describe a standardized laparoscopic kidney transplant procedure in a pig model., Materials and Methods: Ten pigs underwent laparoscopic kidney autotransplant. A right-hand assisted nephrectomy was performed through a Pfannenstiel incision. After the graft was washed with Ringer lactate, it was transplanted into the right iliac vessels by pure laparoscopy. To maintain cold ischemia, a gauze-wrapped ice slush was placed below the allograft. The ureteroneocystostomy was performed through the Pfannenstiel incision. The contralateral ureter was ligated at the end of the procedure. After 24 hours, pigs were killed, and the allograft's perfusion function and presence of urine in the bladder were evaluated., Results: Procedures for 2 animals (20%) could not be completed because of technical problems in the vascular anastomosis; the other 8 procedures (80%) were completed successfully. Seven allografts (87.5%) were functioning 24 hours after surgery, with urine in the bladder and good perfusion of the allograft. The other kidney presented with a venous thrombosis that was detected after death. Mean surgical times were 56.2 ± 11.7 minutes for vein anastomosis and 44.7 ± 23.1 minutes for artery anastomosis. Mean ischemia time was 193 minutes. Total duration of the procedure was clearly decreased in the last 4 animals undergoing transplant., Conclusions: Laparoscopic transplant is a difficult procedure that requires experience in kidney laparoscopy and laparoscopic vascular sutures. The experimental model presented is a good training option and can be used to evaluate different methods to maintain cold ischemia and to compare with the traditional open approach.

Purpose: There is a concern about the impact that this surgery could have on a patient's sexuality, although this has not been well documented. The objective of our study is to describe the surgical results and assess sexual function and patient satisfaction after transvaginal NOTES-assisted laparoscopic radical and living donor nephrectomy., Methods: Between March 2008 and October 2014, 100 women underwent transvaginal NOTES-assisted nephrectomy (78 living donor and 22 radical nephrectomy) in our centre. The procedure was performed using two different techniques depending on the indication as described previously, but using the same vaginal approach. Variables evaluated were operative time, blood loss, intra-operative complications, hospital stay, satisfaction, first-month creatinine and warm ischaemia time in donors. Sexual function was assessed with the Female Sexual Function Index questionnaire before and after surgery. All variables were accrued in a prospective database., Results: The procedure was completed in all cases. Mean age and body mass index was higher in the radical nephrectomy group. Mean operative time and hospital stay were similar for both techniques. All sexually active women reported unaltered sexual function after surgery and satisfaction with the results. The pre- and post-FSFI scores for living donor (n = 54) and radical nephrectomy (n = 4) were 27.47 ± 1.02/27.27 ± 1.10 (p > 0.05) and 31.17 ± 0.81/31.87 ± 0.97 (p > 0.05)., Conclusions: Transvaginal NOTES-assisted or hybrid NOTES nephrectomy offers a safe technique with excellent cosmetic results and no sexual effect. Despite promising results, randomized controlled studies with longer follow-up are warranted to further elucidate the potential of this novel technique.

Objectives: To analyze the predictors for bladder recurrence (BR) after nephroureterectomy (NU) for upper urinary tract tumors (UUTT), as well as its pathological characteristics, outcomes and impact on survival., Material and Methods: Retrospective study of 117 patients who underwent laparoscopic nephroureterectomy by UUTT between 2007-2012 at our center. The potential predictors for BR were analyzed using Cox regression; Kaplan-Meier curves were employed to study survival., Results: The sample was composed of 85 men (73%) and 32 women (27%), with a mean age of 70 years. After a mean follow-up of 26 months, 23 patients presented BR (19.6%). In the multivariate analysis, sex (p=.003; HR [female], 3.8) and the location of the UUTT in the distal ureter (p=.002; HR, 4.8) were independent predictors for BR. The median time to BR was 8 months. Fifteen patients presented a nonmuscle-invasive BR (65.2%), and 8 presented a muscle-invasive BR (34.8%). All BRs, except for 2, appeared during the first 2 years. Five cases with nonmuscle-invasive BR presented a new BR. Six patients with muscle-invasive BR died before it could be determined whether cause of death was the BR or an UUTT relapse. The onset of BR showed no repercussion on the survival of patients with UUTT., Conclusions: Sex (female) and the location of the UUTT (distal ureter) are predictors for BR after NU. Patients with these characteristics might benefit from adjuvant intravesical treatment and closer monitoring. The onset for RV has no impact on the survival of patients with UUTT., (Copyright © 2014 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: The rate of right laparoscopic living-donor nephrectomy (RLLDN) is low among kidney transplantations due to the short renal vein and presumed higher risk of thrombosis. Our objective was to describe a surgical technique to compensate for the shorter veins of these grafts., Methods: Between January 2004 and July 2010, we prospectively collected data from all transplantations using RLLDN-harvested kidneys at our center. Recipient iliac vein transposition was performed in all patients. We reviewed the indications, surgical techniques, and postoperative courses., Results: The 43 included cases showed a 2.1 +/- 0.6 cm, average length of the right renal vein as measured on abdominal computed tomography (CT). The mean extraction and implantation times were 109 +/- 33 and 124 +/- 31 minutes, respectively; the mean warm ischemia time was 151 +/- 29 seconds. Two recipients required postsurgical blood transfusions. In 97.6% of cases, there was immediate urine flow. Postoperative echo-Doppler revealed good arterial and venous flows in all patients. No venous thromboses were detected. The recipients' average hospital stay was 8 +/- 5 days. With a mean follow-up of 57 months, 86% of recipients maintain a glomerular filtration rate (GFR) >50 mL/min and creatinine levels <1.5 mg/dL., Conclusions: Transposition of the recipient iliac vein during implantation is a good technical solution to compensate for the short length of the right renal vein. The use of iliac vein transposition allowed us to perform safe implants of RLLDN-harvested kidneys with good short-term and long-term results., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: Bleeding after partial nephrectomy can be immediate or delayed and may have severe consequences. The incidence of this complication is low. The most frequent cause of delayed bleeding is arterial pseudoaneurysm. Superselective embolization is a feasible therapeutic option that has shown good results., Objective: To evaluate treatment and outcomes of delayed bleeding in our series of patients with partial nephrectomy., Material and Methods: We performed a retrospective study of our database of partial nephrectomies. Patients who developed delayed bleeding (after discharge) were identified. Clinical histories were reviewed and data on presentation, diagnosis, treatment and outcomes were analyzed., Results: Among our series of patients undergoing partial nephrectomy, three developed delayed bleeding (1.3%). Symptom onset occurred 17 to 25 days after surgery and consisted of hematuria or lumbar pain. Diagnosis was provided through ultrasound, abdominal computed tomography and renal angiography. In all three patients, a complicated pseudoaneurysm was diagnosed and all patients underwent renal artery catheterization with selective renal artery embolization. In all patients, immediate control of bleeding was achieved. Outcome after a follow-up of 61 to 92 months was favorable., Conclusions: Selective vascular embolization is the treatment of choice of renal pseudoaneurysm after partial nephrectomy in hemodynamically stable patients., (Copyright © 2011 AEU. Published by Elsevier Espana. All rights reserved.)

Introduction: LESS surgery (Laparoendoscopic single site surgery) is a surgical technique that aims to perform intraabdominal surgery using a single site entry, allowing for reduction in the number and size of the incisions, achieving better esthetic results with at least the same functional outcomes as with the conventional laparoscopic surgery., Material and Methods: We present the first experience of LESS living donor nephrectomy carried out by a totally European team. To perform it, a Quadport® device was placed through a 4 cm long paraumbilical incision., Results: The nephrectomy was performed using the standards of conventional laparoscopic surgery, with the use of a precurved instrument in the left hand and straight instruments in the right. After bagging the kidney, the artery and vein were sectioned after clipping, allowing for rapid extraction of the organ through the same incision, with warm ischemia of 3.30" and 2.47," respectively., Conclusion: Living donor nephrectomy using the LESS technique is feasible and can be considered a good option for obtaining live donor kidney grafts in males. The application of said surgical in living kidney donor can increase the rate of donation, by reducing morbidity and improving the esthetic results with the same outcome for the donor as for the recipient., (Copyright © 2011 AEU. Published by Elsevier Espana. All rights reserved.)

Background: Natural orifice transluminal endoscopic surgery (NOTES) uses natural orifices to access the abdominal cavity. We adapted NOTES to perform transvaginal NOTES-assisted laparoscopic nephrectomy in living donors., Objective: To assess the feasibility and reproducibility of this procedure and compare it with conventional laparoscopic living donor nephrectomy (LLDN)., Design, Setting, and Participants: From July 2009 to October 2010, 20 women underwent transvaginal NOTES-assisted living donor nephrectomy (LDN) in our centre. We compared the prospectively collected clinical data of each donor with those of a contemporaneous matched pair of conventional LLDNs (40 donors)., Surgical Procedure: The procedure was performed using three abdominal trocars and one trocar through the vaginal wall., Measurements: Variables evaluated for donors were procedure length, blood loss, warm ischaemia time (WIT), complications, hospital stay, and first-month creatinine nadir. In the transvaginal LDN group, sexual function was assessed with the Female Sexual Function Index questionnaire before and after surgery. Variables evaluated for recipients were complications, graft function, and creatinine evolution., Results and Limitations: The procedure was completed in all cases. Operative variables were similar for both groups except for WIT, which was longer in the transvaginal LDN group (p<0.001) without consequences for graft functioning. One transvaginal LDN case had postoperative bleeding requiring immediate open surgery. All transvaginal LDN donors reported unaltered sexual function after surgery and satisfaction with the results. All recipients had immediate urine output, and all had a functioning graft at last follow-up except for one recipient of the transvaginal LDN group who required transplantectomy. Despite promising results, randomised controlled studies with longer follow-up are warranted to further elucidate the potential of this novel technique., Conclusions: Transvaginal NOTES-assisted LDN appears to be a feasible and reproducible surgical technique. The WIT was longer in the transvaginal group, and there was no effect on graft function after the short follow-up., (Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

The incidence of de novo malignancies is an accepted complication of organ transplantation. Renal cell carcinoma (RCC) was 4.6% of cancers occurring de novo in organ allograft recipients compared with 3% in the general population. Less than 10% of these renal cancers affected the renal allograft. Among patients developing a renal tumor in the kidney allograft, transplant nephrectomy reduced the quality of life. For these patients for whom preservation of renal function is a relevant clinical consideration, partial nephrectomy may be considered the choice for treatment. Fifteen cases have been reported regarding conservative surgery on kidney transplant tumors. Herein we have reported three cases of renal masses in well-functioning kidney transplants that were successfully treated with nephon-sparing surgery. Our experience demonstrated that in selected patients, nephron-sparing surgery on a renal allograft represents a feasible approach for tumor removal with preservation of graft function.