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Background: A variety of surgical and nonsurgical management options for small renal masses (SRMs) now exist. Surgery in the form of partial nephrectomy (PN) has three different approaches. It is unclear which PN approach, if any, offers superior clinical outcomes. Aim: The aim of this study is to compare outcomes in patients with SRMs <4 cm undergoing PN through the open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), or robotic partial nephrectomy (RPN) approach and to establish the advantages and disadvantages of the various approaches. Methods: A systematic literature search was conducted for studies comparing at least two of the above techniques. Eighteen studies and 17,013 patients were included in our study. A network meta-analysis with a frequentist framework was performed. OPN was used as the baseline comparator. The prespecified primary outcome was R0 resection rates. Secondary outcomes included operating time, ischemia time, blood loss, transfusion rates, urine leak rates, significant morbidity, length of stay, and recurrence. Results: There was no significant difference between the techniques in terms of R0 rates, tumor recurrence, urine leak rates, renal function, and >3a Clavien-Dindo complications. LPN had a longer ischemic time and operating time. OPN had a longer length of stay and higher average intraoperative blood loss. RPN had lower blood transfusion rates. Discussion: All approaches are acceptable from an oncological perspective. The minimally invasive approaches (i.e., RPN and LPN) offer advantages in terms of morbidity; however, LPN may increase ischemic time and operative duration. Variations between perioperative outcomes may influence the choice of approach on a case-by-case and institutional basis.

Background: The decision to perform a partial nephrectomy (PN) relies largely upon the complexity of the renal mass and its surrounding anatomy. The presence of adherent perinephric fat (APF) can increase surgical complexity and extend operative times. The accurate prediction of APF may improve surgical planning and aid in decision making for the surgical approach., Objective: We sought to develop and externally validate a score that predicts APF based on preoperative clinical and radiological prognostic factors., Design, Setting, and Participants: We retrospectively analyzed 495 consecutive patients who underwent open or minimally invasive PN. APF was defined as the presence of "dense," "adherent," or "sticky" perinephric fat at the time of dissection by the surgeon, and this did not require subcapsular dissection. Additionally, we analyzed an independent cohort of 285 patients for external validation., Outcome Measurements and Statistical Analysis: A score model was developed using multivariate logistic regression analysis. Calibration of the fitted model was assessed graphically with a plot of the predicted versus the actual probability of APF, and discrimination was assessed by calculating the area under the receiver operating characteristic curve., Results and Limitations: Of the 495 patients, 95 (19%) had APF. Patients with APF had longer operative (p=0.02) and arterial clamp (p=0.01) times than non-APF patients. On multivariate analyses, diabetes mellitus (p=0.009), posterior perinephric fat thickness (p<0.001), and perinephric stranding (p<0.001) were predictors of encountering APF in PN. A risk score ranging from 0 to 4 was developed based on these three variables to predict APF. The scoring system demonstrated good discrimination of 0.82 and 0.84 for the development and external validation cohorts, respectively., Conclusions: The APF score can accurately predict the presence of APF in patients with a small renal mass who are planning to undergo PN. This score could aid in pre- and intraoperative planning and impact the surgical approach., Patient Summary: The presence of "sticky" fat surrounding the kidney in patients undergoing partial nephrectomy has previously been linked to longer operative times, intraoperative complications, and surgical conversion. In our study, we found that this feature is more often presented in patients with diabetes mellitus, and thicker and more inflammatory fat on renal imaging. Based on these findings, we developed a risk score that can accurately predict this feature before surgery, in order to improve surgical planning and better counsel the patients., (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To study the natural history, prognosticators, and outcomes in patients with renal cell carcinoma (RCC) with extension of tumor beyond Gerota׳s fascia or invading contiguously into the adrenal gland (pT4) or both., Patients and Methods: From 1992 to 2012, we identified 61 patients who underwent radical nephrectomy and were found to have pT4 disease. Clinicopathologic variables were queried using univariate analysis to identify relevant prognostic variables. Cox proportional hazards model was used for multivariate analysis of predictors of cancer-specific survival. Survival plots were estimated using Kaplan-Meier method and survival analysis using log-rank test., Results: Median age was 56 years (interquartile range: 49-64) and 49 (81.7%) patients had Eastern Cooperative Oncology Group Performance Status 0 or 1. At diagnosis, 22 (36.1%) patients showed nonmetastatic and 39 (63.9%) patients showed metastatic RCC. Overall, 49 (80.3%) patients had clear cell RCC, 24 (39.3%) patients had sarcomatoid features, and 39 (69.6%) patients had Fuhrman grade 3 to 4. There were 26 (42.6%) patients with pN0, 16 (26.2%) patients with pN1, and 19 (31.1%) patients with pNx. Median cancer-specific survival was 37 months for patients with nonmetastatic and 8 months for patients with metastatic RCC. On multivariate analysis, preoperative lactate dehydrogenase and alkaline phosphatase, M stage, pN stage, and sarcomatoid dedifferentiation were significantly associated with survival., Conclusions: Survival in patients with pT4 remains poor. The pT4 disease is associated with a locally and regionally invasive biology that requires specific attention and warrants careful study. Understanding the drivers of this unique phenotype would generate therapeutic interventions that can change the behavior of these uniquely aggressive tumors., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Among patients with renal cell carcinoma (RCC), 25-30% present with metastatic disease at the time of initial diagnosis. Despite the ever-increasing array of treatment options available for these patients, surgery remains one of the cornerstones of therapy. Proper patient selection for cytoreductive surgery is paramount to its effective use in the management of patients with metastatic RCC despite the decrease in reported morbidity rates. We explore the evolving role cytoreductive surgery in metastatic RCC spanning the immunotherapy era to the targeted therapy era. Despite significant advances in the management of patients with metastatic RCC, further evidence on the definitive role of cytoreductive surgery in the targeted therapy era is awaited through large randomized trials., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Isolated local retroperitoneal recurrence after radical nephrectomy for renal cell carcinoma poses a therapeutic challenge. We investigated outcomes in patients with localized retroperitoneal recurrence treated with surgical resection., Materials and Methods: This was a retrospective, single institutional study of 102 patients with retroperitoneal recurrence treated with surgery from 1990 to 2014. Demographics, clinical and pathological features, location of retroperitoneal recurrence and perioperative complications are reported using descriptive statistics. We studied recurrence-free and cancer specific survival using univariate and multivariate analyses., Results: Median age at retroperitoneal recurrence diagnosis was 55 years (IQR 49-64). Cancer was pT3-4 in 62 patients (60.8%) and pN1 in 20 (19.6%). No patients had distant metastatic disease at retroperitoneal recurrence surgery. Median time from nephrectomy to retroperitoneal recurrence diagnosis was 19 months (IQR 5-38.8). The median size of the resected retroperitoneal recurrence was 4.5 cm (IQR 2.7-7). Median followup after recurrence surgery was 32 months (IQR 16-57). Metastatic progression was observed in 60 patients (58.8%) postoperatively. Neoadjuvant and salvage systemic therapy was administered in 46 (45.1%) and 48 patients (47.1%), respectively. On multivariate analysis pathological nodal stage at original nephrectomy and maximum diameter of retroperitoneal recurrence were identified as independent risk factors for cancer specific death., Conclusions: Clinicopathological factors at nephrectomy as well as retroperitoneal recurrence surgery are important prognosticators. Aggressive surgical resection offers potential cure in a substantial number of patients with retroperitoneal recurrence with acceptable complications and still has a dominant role in the management of isolated locally recurrent RCC., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Laser technology presents a promising alternative to achieve tumor excision and renal hemostasis with or without hilar occlusion, yet its use in partial nephrectomy has not been significantly evaluated. We prospectively evaluated the thulium:yttrium-aluminum-garnet laser in laparoscopic partial nephrectomy (LPN) in our institution over a 1-year period., Patients and Methods: We used the thulium laser with a wavelength of 2013 nm in the infrared spectrum. Data were recorded prospectively. Tumor size, preoperative aspects and dimensions used for an anatomical classification (PADUA) score, operative time, warm ischemia time (WIT), and perioperative and postoperative morbidity were recorded. Blood loss, preoperative and postoperative creatinine level, and estimated glomerular filtration rate (eGFR) were also collected., Results: A total of 15 patients underwent consecutive LPN. The mean tumour diameter was 2.85 (1.5-4). The mean PADUA score was 6.8 (6-9). The mean total operative time was 168 minutes (128-306 min). Mean blood loss was 341 mL (0-800 mL). Date of discharge was 3.2 days postoperatively (2-8 days). The renal vessels were not clamped, resulting in a WIT of 0 minutes in all cases. There was no statistical significant increase in serum creatinine level or decrease in eGFR postoperatively. Histologically, the majority of lesions (13/15 patients) were renal-cell carcinoma stage pT1a. In all cases, base margins had negative results for tumor., Conclusion: The 2013-nm thulium laser system offers excellent hemostasis and precise resection capability of the renal cortex during LPN of small partially exophytic renal tumors. Our series showed excellent perioperative functional and pathologic outcomes, including minimal blood loss, zero ischemia, negative tumor margins, and preservation of renal function.