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Introduction: The proportion of robotic procedures continues to rise. The literature reinforces that robotic procedures take longer and are often more costly. We compared cost and perioperative out...

Objective To use a randomized, prospective, multi-institutional study to compare the safety and efficacy of conventional insufflation (CIS) and valveless insufflation (AirSeal Insufflation – AIS) at the conventional pressure of 15 mm Hg in robot-assisted partial nephrectomy – a surgery where AIS has gained popularity for maintaining visualization despite suction. This study was also powered to evaluate the effect of decreasing pneumoperitoneum by 20% in the valveless system. Materials and Methods Three high-volume institutions randomized subjects into CIS 15, AIS 15, and AIS 12 mm Hg cohorts. Endpoints included rates of subcutaneous emphysema (SCE), pneumothorax (PTX), pneumomediastinum (PMS), intraoperative end-tidal carbon dioxide (ET CO2), and peak airway pressure (PAP), as well as hospital stay, post-operative pain, and complications. Given the substantial proportion of retroperitoneal surgery, a secondary analysis evaluated the effect of surgical approach. Results Two hundred and two patients were accrued. SCE was decreased in the AIS 12 mm Hg group (p=0.003). PTX and PMS rates were not statistically significantly different across the 3 insufflation groups. Higher rates of SCE and PMS, although not PTX, were noted in all retroperitoneal surgery groups – with lower SCE rates for AIS 12 mm Hg regardless of surgical approach. Conclusion AIS is often preferred for complex procedures including retroperitoneal and transperitoneal robotic-assisted partial nephrectomy, for its maintenance of pneumoperitoneum despite continuous suction necessary for visualization. This study shows that AIS is safe when compared to CIS at 15 mm Hg, and shows improvement in outcomes when pneumoperitoneum pressure is reduced by 20% to 12 mmHg.

Introduction: With increased demands on surgeon productivity and outcomes, residency robotics training increasingly relies on simulations. The objective of this study is to assess the validity and ...

Introduction: Percutaneous cryoablation (PCA) has emerged as an alternative to extirpative management of small renal masses (SRMs) in select patients, with a reduced risk of perioperative complicat...

Our objective was to assess the diagnostic accuracy of

Introduction and Objective: Retzius-sparing robot-assisted laparoscopic prostatectomy (RS-RALP) was first described in 2010. Since that time, a new single-port (SP) robotic platform was ap...

Background Local‐regional failure (LF) for locally advanced bladder cancer (LABC) after radical cystectomy (RC) is common even with chemotherapy and is associated with high morbidity/mortality. Postoperative radiotherapy (PORT) can reduce LF and may enhance overall survival (OS) but has no defined role. We hypothesized that the addition of PORT would improve OS in LABC in a large nationwide oncology database. Methods We identified ≥ pT3pN0‐3M0 LABC patients in the National Cancer Database diagnosed 2004‐2014 who underwent RC ± PORT. OS was calculated using Kaplan‐Meier and Cox proportional hazards regression modeling was used to identify predictors of OS. Propensity matching was performed to match RC patients who received PORT vs those who did not. Results 15,124 RC patients were identified with 512 (3.3%) receiving PORT. Median OS was 20.0 months (95% CI, 18.2‐21.8) for PORT vs 20.8 months (95% CI, 20.3‐21.3) for no PORT (P = 0.178). In multivariable analysis, PORT was independently associated with improved OS: hazard ratio 0.87 (95% CI, 0.78‐0.97); P = 0.008. A one‐to‐three propensity match yielded 1,858 patients (24.9% receiving PORT and 75.1% without). In the propensity‐matched cohort, median OS was 19.8 months (95% CI, 18.0‐21.6) for PORT vs 16.9 months (95% CI, 15.6‐18.1) for no PORT (P = 0.030). In the propensity‐matched cohort of urothelial carcinoma patients (N = 1,460), PORT was associated with improved OS for pT4, pN+, and positive margins (P

To identify avoidable predictors of postureteroscopy (URS) unplanned encounters and to minimize 30-day encounters.We performed retrospective chart review and telephone surveys on patients who underwent URS for urolithiasis between January and June 2016. Univariate and multivariable analyses evaluated for potential predictors of unplanned encounters.Of 157 patients, there were 44 (28.0%) unplanned patient-initiated clinical phone calls, 23 (14.6%) emergency department (ED) visits, and 8 (5.1%) readmissions, with pain being the most common complaint during the encounters. Factors associated with a higher rate of phone calls include first-time stone procedure (36.6% vs 20.9%, p = 0.029), outpatient status (30.3% vs 0%, p = 0.021), intraoperative stent placement (31.2% vs 0%, p = 0.006), and stent removal at home (58.8% vs 28.8%, p = 0.014). Factors associated with increased rate of ED visits were first-time stone procedure (22.5% vs 8.1%, p = 0.011) and ureteral access sheath (UAS) usage (29.6% vs 11.8%, p = 0.018). Factors associated with a higher rate of readmissions were lower body mass index (23.9 vs 29.7, p = 0.013), bilateral procedure (20.0% vs 2.9%, p = 0.010), and UAS usage (14.8% vs 3.1%, p = 0.032). Stone burden, operative time, Charlson comorbidity index, and preoperative urinary tract infection were not significantly associated with postoperative encounters.Pain, first-time stone treatment, presence of a ureteral stent, outpatient status, bilateral procedures, and UAS usage were common reasons for postoperative encounters after URS. Appropriate perioperative patient education and counseling and adequate pain management may minimize these encounters and improve treatment quality and patient satisfaction.

Introduction: Herein we evaluate the incidence of incisional lumbodorsal hernia (ILDH) after retroperitoneal robotic partial nephrectomy (RRPN) and associated patient-specific and tumor-specific ri...

Introduction and Objective: African American (AA) race has been identified to have a higher incidence of chronic kidney disease (CKD) and worse renal cancer survival compared with Caucasian America...

Background: The surgical techniques and devices used to perform radical cystectomy have evolved significantly with the advent of laparoscopic and robotic methods. The da Vinci® Single-Port (SP) pla...

Background: Delayed proximal ureteral stricture (DPUS) after nephron-sparing treatment (partial nephrectomy [PN] and image-guided percutaneous ablation) of renal masses is a rare complication that occurs because of an unrecognized injury to the proximal ureter and/or its associated vascular supply. We present a multi-institutional series of patients who developed DPUS after nephron-sparing treatment and review relevant tumor characteristics, timing of DPUS presentation, presenting symptoms, and outcome of stricture management. Case Presentation: Between 2000 and 2019, nine patients (five PN and four ablation) were found to have DPUS diagnosed at an average of 9 (6–119) months after PN and 5.5 (1–6) after ablation. Average tumor size was 4.5 (2.9–7.3) cm and 3.6 (3–4.1) cm for those treated with PN and ablation, respectively. Nephrometry score was 8.3 (6–11) and 6.5 (5–8), respectively. For resected tumors, all were located in the lower pole, but uniformity was not found as far as medial vs lateral (3 vs 2), anterior vs posterior (2 vs 2, 1 N/A), and right vs left (3 vs 2). For ablated tumors, all four tumors were right sided, anterior, medial, and lower pole. Initial signs and symptoms include sepsis (2), flank pain (5), and asymptomatic hydronephrosis (2). Concomitant urinoma (2) and retroperitoneal abscess (1) was found on imaging. Initial management included ureteral stenting (5) and percutaneous nephrostomy tube (4). Three underwent nephrectomy. Two had spontaneous resolution of DPUS after a course of ureteral stenting. Conclusion: Potential risk factors associated with DPUS after nephron-sparing treatment, including medial and lower pole tumors, and particularly right-sided anterior masses for ablation and higher complexity nephrometry score for PN. Recognition of delayed symptoms and imaging abnormalities in the surveillance period should cue clinical suspicion to DPUS.

Background Combination checkpoint inhibitor immunotherapy has recently become a new frontline standard of care for metastatic renal cell carcinoma (mRCC). Previously published data has demonstrated a survival benefit of cytoreductive nephrectomy (CN) in the interferon era, but the utility of CN in conjunction with the use of tyrosine kinase inhibitors (TKIs) has been controversial. Patients In the current case series, we report on five patients with IMDC intermediate- or poor-risk initially unresectable metastatic renal cell carcinoma who successfully underwent CN. Results All patients received induction combination checkpoint inhibitor immunotherapy (CPI) ipilimumab-nivolumab with or without pembrolizumab-axitinib. Three patients underwent robotic CN, and one patient underwent open and laparoscopic CN, respectively. Three of the five patients were found to have significant fibrosis and desmoplastic reaction at the time of nephrectomy, requiring surgical expertise and increased operative time. Conclusions Herein we highlight the feasibility of this approach and the post-CPI surgical challenge of CN. The role of CN in patients receiving systemic therapy with CPI is not yet defined and is quickly evolving.

INTRODUCTION AND OBJECTIVE:Positive surgical margins (PSM) in patients who undergo robotic partial nephrectomy (RPN) for clinically localized renal masses have been shown to be associated with an i...

INTRODUCTION AND OBJECTIVE:The use of valve-less insufflation is gaining significant popularity for robotic partial nephrectomy secondary to its ability to maintain a pneumoperitoneum during consta...

Objective To provide a training tool to address the technical challenges of robot-assisted laparoscopic partial nephrectomy, we created silicone renal tumor models using 3-dimensional printed molds of a patient's kidney with a mass. In this study, we assessed the face, content, and construct validity of these models. Materials and Methods Surgeons of different training levels completed 4 simulations on silicone renal tumor models. Participants were surveyed on the usefulness and realism of the model as a training tool. Performance was measured using operation-specific metrics, self-reported operative demands (NASA Task Load Index [NASA TLX]), and blinded expert assessment (Global Evaluative Assessment of Robotic Surgeons [GEARS]). Results Twenty-four participants included attending urologists, endourology fellows, urology residents, and medical students. Post-training surveys of expert participants yielded mean results of 79.2 on the realism of the model's overall feel and 90.2 on the model's overall usefulness for training. Renal artery clamp times and GEARS scores were significantly better in surgeons further in training (P ≤.005 and P ≤.025). Renal artery clamp times, preserved renal parenchyma, positive margins, NASA TLX, and GEARS scores were all found to improve across trials (P Conclusion Face, content, and construct validity were demonstrated in the use of a silicone renal tumor model in a cohort of surgeons of different training levels. Expert participants deemed the model useful and realistic. Surgeons of higher training levels performed better than less experienced surgeons in various study metrics, and improvements within individuals were observed over sequential trials. Future studies should aim to assess model predictive validity, namely, the association between model performance improvements and improvements in live surgery.

BackgroundTreatment of localized prostate cancer with surgery or radiotherapy remains suboptimal with failure rates of 35–40%.1 Neoadjuvant androgen deprivation therapy improved pathologic outcomes, but did not significantly impact progression-free or overall survival.2 Prostate cancer with higher density of B cells correlates with higher stage disease and higher risk of recurrence or progression.3 Elevated levels of BTK (Bruton’s tyrosine kinase) – an enzyme known to have critical roles in B cell function - have also been noted in prostate cancer compared to normal prostate tissue, correlate with cancer grade, and may play a role in prostate tumorigenesis. Preclinical modeling shows pharmacologic suppression of BTK inhibits growth of prostate cancer.4 Ibrutinib, a potent BTK inhibitor, can target B-cell signaling pathways and has an established safety profile. Ibrutinib may act to reduce immunosuppression by intratumoral B cells, which can secrete anti-inflammatory IL-10 and inhibit Th1 and cytotoxic CD8 T cell activity.5 Therefore, we hypothesized that ibrutinib will augment anti-tumor immune responses in localized prostate cancer.MethodsAccrual began in July 2016 for this ongoing trial (NCT02643667). 23 of 24 planned patients have been enrolled to date. Eligible patients have received no prior treatment for their histologically confirmed prostatic adenocarcinoma and have no evidence of metastatic disease. Patients must have decided upon surgery and been deemed suitable candidates to undergo a radical prostatectomy. Following completion of an initial three patient safety cohort of 840 mg, qd ibrutinib dosing for 14 days, all remaining patients receive treatment with 840 mg/day oral ibrutinib for 28 days. Radical prostatectomy will occur 7–12 days after the last dose of ibrutinib. Patients are assessed 4 weeks after surgery. The primary objectives are to assess safety of ibrutinib and characterize B and T cell infiltration within prostate tissue in the ibrutinib treated patients compared to a reference population. Correlative tissue samples will be obtained to characterize the B and T cell infiltration within prostate tissue treated with ibrutinib compared to an untreated reference population. Correlative blood samples will be used to investigate circulating B and T cells induced by ibrutinib. BTK and PD-L1 expression in tumor and immune-infiltrating immune cells will also be examined. This is the first clinical trial of ibrutinib in prostate cancer, lays the foundation for larger future studies.Trial RegistrationNCT02643667ReferencesKuban DA, Thames HD, Levy LB, et al. Long-term multi-institutional analysis of stage T1-T2 prostate cancer treated with radiotherapy in the PSA era. Int J Radiat Oncol Biol Phys 2003 Nov 15;57(4):915–28. PubMed PMID: 14575822.Scolieri MJ, Altman A, Resnick MI. Neoadjuvant hormonal ablative therapy before radical prostatectomy: a review. Is it indicated? J Urol 2000 Nov;164(5):1465–72. PubMed PMID: 11025684.Woo JR, Liss MA, Muldong MT, et al. Tumor infiltrating B-cells are increased in prostate cancer tissue. J Transl Med 2014 Jan 30;12–30. Pubmed PMID: 24475900.Guo W, Liu R, Bhardwaj G, et al. Targeting Btk/Etk of prostate cancer cells by a novel dual inhibitor. Cell Death Dis 2014 Sep 4;5:e1409. PubMed PMID: 25188519.Gunderson AJ, Coussens LM. B cells and their mediators as targets for therapy in solid tumors. Exp Cell Res 2013 Jul 1;319(11):1644–9. PubMed PMID: 23499742.Ethics ApprovalThis study obtained ethics approval from the Washington University School of Medicine IRB (#201808057), and participating individuals gave informed consent before taking part.

Treatment modalities for small renal masses (SRMs) include open or minimally invasive radical or partial nephrectomy, and laparoscopic or percutaneous ablations. Members of the Endourological Society were surveyed to evaluate how practitioner and clinical practice characteristics may be associated with the management of SRMs over time. The survey assessed characteristics of urologists (recency of residency and fellowship training, clinical practice type and location, and treatment modalities available) and their management of SRMs over the past year and over the course of the year 5 years prior. Of the 1495 surveys e-mailed, there were 129 respondents (8.6%). Comparing the past year to 5 years prior, there was increasing utilization of robotic partial nephrectomy (p < 0.001) and robotic radial nephrectomy (p = 0.031). In contrast, there was decreasing utilization of open partial nephrectomy (p < 0.001), open radical nephrectomy (p = 0.039), laparoscopic partial nephrectomy (p = 0.002), and laparoscopic radical nephrectomy (p = 0.041). Employment of laparoscopic ablation decreased (p = 0.001), but that of percutaneous ablation did not change significantly. For masses treated with image-guided therapy, there was increasing utilization of microwave ablation (p = 0.008) and decreasing usage of radiofrequency ablation (p = 0.002). Future studies should focus on the most effective treatment modalities based on provider, patient, and tumor characteristics.

Approximately 5% of angiomyolipomas (AMLs) are classified as "fat poor" due to lack of visually detectable fat on imaging, making them difficult to distinguish from renal cell carcinoma. Recent investigations have proposed CT and MR imaging features suggestive of fat-poor AML (fp-AML). Herein, we determined the frequency of these features in a cohort of fp-AMLs by retrospective review of preoperative imaging.A pathology database query from January 2005 to August 2013 identified 49 renal specimens of AML with available imaging. A retrospective review of all CT and MR images of these 49 cases was conducted. Cases with visually detectable fat on imaging were excluded.A total of 26 fp-AMLs were identified. Thirteen lesions had available unenhanced CT images, of which eight (62%) were hyperdense compared to the adjacent renal parenchyma, while five (38%) were isodense. Twenty lesions had enhanced CT images: 14 (70%) and 6 (30%) with homogeneous and heterogeneous enhancement, respectively. Of the nine lesions with enhanced MR sequences, five (56%) were homogeneously enhancing, and four (44%) were heterogeneously enhancing. Eight of nine (89%) lesions had hypointense signal intensity (SI) on T2-weighted MR sequences, while one (11%) had hyperintense SI. None of the eight lesions displayed a decrease in signal on fat-suppressed sequences.In this study, we confirmed common imaging features of fp-AML: high attenuation on unenhanced CT sequences, homogeneous enhancement on CT, and hypointensity on T2-weighted MR. When these features are present, a renal mass biopsy may be prudent.

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.We sought to develop and externally validate a score that predicts APF based on preoperative clinical and radiological prognostic factors.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.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.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 (p0.001), and perinephric stranding (p0.001) 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.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.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.

To identify specific comorbidities within the Charlson Comorbidity Index (CCI) that are associated with increased complication rates after robot-assisted partial nephrectomy (RAPN).After institutional review board approval, a consecutive series of 641 patients undergoing RAPN were retrospectively identified. Perioperative complications were defined and classified using the Clavien grading system. Fisher's exact test or chi-square test was performed to evaluate the association of individual comorbidities with perioperative complications. Logistic regression was used for multivariable analysis to adjust for other non-CCI comorbidities and tumor-specific and patient-specific characteristics.Of the 641 patients undergoing RAPN, complications occurred in 67 patients (10.5%), including 10 (14.9%), 28 (41.8%), 20 (29.9%), 5 (7.5%), and 4 (6.0%) patients with Clavien grade 1, 2, 3a, 3b, and 4 complications, respectively. Cerebrovascular disease [odds ratio 3.01 (95% confidence interval [CI] 1.10, 8.26) p = 0.03] and chronic obstructive pulmonary disease [COPD; 3.12 (1.24, 7.89) p = 0.02] predicted complications in multivariable analysis of clinicopathologic characteristics, including all CCI and non-CCI comorbidities. In additional modeling with only CCI comorbidities, similar results were observed, with cerebrovascular disease [2.93 (1.04, 7.56) p = 0.04] and COPD [2.69 (1.04, 6.28) p = 0.04] as the only two significant variables. No other variables reached statistical significance in either model, including nephrometry score or estimated blood loss (p .50 for both). COPD predicted major complications (Clavien grade 3 or 4) in multivariable analysis [3.19 (1.07, 9.48) p = 0.04].Cerebrovascular disease and COPD predict perioperative RAPN complications after RAPN. Identification of patients with these comorbidities preoperatively may afford improved counseling and risk stratification.

OBJECTIVE: Small renal masses (SRMs) ≤4cm are malignant in the majority of cases. Renal mass biopsy (RMB) can prevent resection of benign lesions but are often followed by a second procedure if malignancy is found. Urine aquaporin-1 (AQP1) and perilipin-2 (PLIN2) have been identified as potential biomarkers for renal cell carcinoma. Here, we evaluate their role as a complimentary adjunct to RMB in guiding management of patients with SRMs. METHODS: Preoperative AQP1 and PLIN2 levels in 57 patients with SRMs undergoing partial nephrectomy were analyzed and compared to postoperative tumor histology. An algorithm was created utilizing AQP1 and PLIN2 in conjunction with RMB. Cutoff values were implemented to maximize biomarker sensitivity and specificity. RMB utilization and intervention were then compared to rates in traditional RMB algorithms. RESULTS: All clear cell and papillary RCCs were correctly identified and assigned to the treatment path. All benign lesions were correctly sorted to a confirmatory RMB path. Two chromophobe masses did not have elevated AQP1 and PLIN2 and would require RMB. Compared to protocols that call for all SRMs to be biopsied, confirmatory RMB could have been safely avoided in 74% of patients with elevated AQP1 and PLIN2. Compared to protocols that do not utilize RMB, surgical intervention would have been avoided in 23% of patients with benign masses. CONCLUSIONS: AQP1 and PLIN2 possess high sensitivity and specificity for detecting clear cell and papillary renal cell carcinoma. Use of these markers may compliment RMB in the characterization of SRMs.

Highlights • Limited information is known about treatment outcomes for squamous cell carcinoma of the bladder (SqCC). • Treatment for SqCC is extrapolated from urothelial carcinoma. • Outcomes of chemoRT for SqCC are very limited. • Following chemoRT, patients with SqCC do worse than counterparts with urothelial carcinoma., Introduction Squamous cell carcinoma (SqCC) is the second most common histology of primary bladder cancer, but still very limited information is known about its treatment outcomes. Most bladder cancer trials have excluded SqCC, and the current treatment paradigm for localized SqCC is extrapolated from results in urothelial carcinoma (UC). In particular, there is limited data on the efficacy of definitive chemo-radiotherapy (CRT). In this study, we compare overall survival outcomes between SqCC and UC patients treated with definitive CRT. Materials/methods We queried the National Cancer Database (NCDB) for muscle-invasive (cT2-T4 N0 M0) bladder cancer patients diagnosed from 2004 to 2013 who underwent concurrent CRT. Propensity matching was performed to match patients with SqCC to those with UC. OS was analyzed using the Kaplan-Meier survival method, and the log-rank test and Cox regression were used for analyses. Results 3332 patients met inclusion criteria of which 79 (2.3%) had SqCC. 73.4% of SqCC patients had clinical T2 disease compared to 82.5% of UC patients. Unadjusted median OS for SqCC patients was 15.6 months (95% CI, 11.7–19.6) versus 29.1 months (95% CI, 27.5–30.7) for those with UC (P

Hypertriglyceridemia is an independent risk factor for cardiovascular disease. Dietary interventions based on protein restriction (PR) reduce circulating triglycerides (TGs), but underlying mechanisms and clinical relevance remain unclear. Here, we show that 1 week of a protein-free diet without enforced calorie restriction significantly lowered circulating TGs in both lean and diet-induced obese mice. Mechanistically, the TG-lowering effect of PR was due, in part, to changes in very low-density lipoprotein (VLDL) metabolism both in liver and peripheral tissues. In the periphery, PR stimulated VLDL-TG consumption by increasing VLDL-bound APOA5 expression and promoting VLDL-TG hydrolysis and clearance from circulation. The PR-mediated increase in Apoa5 expression was controlled by the transcription factor CREBH, which coordinately regulated hepatic expression of fatty acid oxidation-related genes, including Fgf21 and Ppara. The CREBH-APOA5 axis activation upon PR was intact in mice lacking the GCN2-dependent amino acid-sensing arm of the integrated stress response. However, constitutive hepatic activation of the amino acid-responsive kinase mTORC1 compromised CREBH activation, leading to blunted APOA5 expression and PR-recalcitrant hypertriglyceridemia. PR also contributed to hypotriglyceridemia by reducing the rate of VLDL-TG secretion, independently of activation of the CREBH-APOA5 axis. Finally, a randomized controlled clinical trial revealed that 4-6 weeks of reduced protein intake (7%-9% of calories) decreased VLDL particle number, increased VLDL-bound APOA5 expression, and lowered plasma TGs, consistent with mechanistic conservation of PR-mediated hypotriglyceridemia in humans with translational potential as a nutraceutical intervention for dyslipidemia.

Objective To evaluate the incidence of and risk factors for a urine leak in a large multicentre, prospective database of robot-assisted partial nephrectomy (RPN). Patients and Methods A database of 1 791 RPN from five USA centres was reviewed for urine leak as a complication of RPN. Patient and tumour characteristics were compared between patients with and those without postoperative urine leaks. Fisher's exact test was used for qualitative variables and Wilcoxon sum-rank tests were used for quantitative variables. A review of the literature on PN and urine leak was conducted. Results Urine leak was noted in 14/1 791 (0.78%) patients who underwent RPN. The mean (sd) nephrometry score of the entire cohort was 7.2 (1.9), and 8.0 (1.9) in patients who developed urine leak. The median (range) postoperative day of presentation was 13 (3–32) days. Patients with urine leak presented in delayed fashion with fever (two of the 14 patients, 14%), gastrointestinal complaints (four patients, 29%), and pain (five patients, 36%). Eight of the 14 patients (57%) required admission, while eight (57%) and nine (64%) had a drain or stent placed, respectively. Drains and stents were removed after a median (range) of 8 (4–13) days and 21 (8–83) days, respectively. Variables associated with urine leak included tumour size (P = 0.021), hilar location (P = 0.025), operative time (P = 0.006), warm ischaemia time (P = 0.005), and pelvicalyceal repair (P = 0.018). Upon literature review, the historical incidence of urine leak ranged from 1.0% to 17.4% for open PN and 1.6–16.5% for laparoscopic PN. Conclusion The incidence of urine leak after RPN is very low and may be predicted by some preoperative factors, affording better patient counselling of risks. The low urinary leak rate may be attributed to the enhanced visualisation and suturing technique that accompanies the robotic approach.

The current TNM system for renal cell carcinoma (RCC) merges perirenal fat invasion (PFI) and renal vein invasion (RVI) as stage pT3a despite limited evidence concerning their prognostic equivalence. In addition, the prognostic value of PFI compared to pT1-pT2 tumors remains controversial.To analyze the prognostic significance of PFI, RVI, and tumor size in pT1-pT3a RCC.Data for 7384 pT1a-pT3a RCC patients were pooled from 12 centers. Patients were grouped according to stages and PFI/RVI presence as follows: pT1-2N0M0 (n=6137; 83.1%), pT3aN0M0 + PFI (n=1036; 14%), and pT3aN0M0 (RVI ± PFI; n=211; 2.9%).Radical nephrectomy or nephron-sparing surgery (NSS) (1992-2010).Cancer-specific survival was estimated using the Kaplan-Meier method. Univariate and multivariate Cox proportional-hazards regression models, as well as sensitivity and discrimination analyses, were used to evaluate the impact of clinicopathologic parameters on cancer-specific mortality (CSM).Compared to stage pT1-2, patients with stage pT3a RCC were significantly more often male (59.4% vs 53.1%) and older (64.9 vs 62.1 yr), more often had clear cell RCC (85.2% vs 77.7%), Fuhrman grade 3-4 (29.4% vs 13.4%), and tumor size7 cm (39.1% vs 13%), and underwent NSS less often (7.5% vs 36.6%; all p0.001). According to multivariate analysis, CSM was significantly higher for the PFI and RVI ± PFI groups compared to pT1-2 patients (hazard ratio [HR] 1.94 and 2.12, respectively; p0.001), whereas patients with PFI only and RVI ± PFI did not differ (HR 1.17; p=0.316). Tumor size instead enhanced CSM by 7% per cm in stage pT3a (HR 1.07; p0.001) with a 7 cm cutoff yielding the highest prediction accuracy.Since the prognostic impact of PFI and RVI on CSM seems to be comparable, merging both as stage pT3a RCC might be justified. Enhanced prognostic discrimination of stage pT3a RCC appears to be possible by applying a tumor size cutoff of 7 cm within an alternative staging system.Prognosis prediction for patients with localized renal cell carcinoma up to stage pT3a can be enhanced by including tumor size with a cutoff of 7 cm as an additional parameter in the TNM classification system.

Lymphoepithelioma-like carcinoma (LELC) is a rare finding in the upper urinary tract. The presenting clinical findings mimic those of other more common upper-tract tumors, such as urothelial carcinoma. Preoperative imaging has not been shown to reliably predict the diagnosis of LELC. This tumor can be misdiagnosed as a reactive inflammatory lesion or lymphoma if the proper immunohistochemical stains for cytokeratin are not used.

The aim of this study was to investigate the incidence of benign histology after partial nephrectomy (PN) in patients with presumed malignancy from preoperative imaging. Furthermore, preoperative predictors of benign lesions and perioperative outcomes were also assessed.A series of patients undergoing PN for renal masses was identified using a prospectively maintained database. Patients were excluded for known genetic conditions, if more than one renal mass was resected, or if standard preoperative imaging was not suspicious for renal-cell carcinoma (RCC). Differences in characteristics between patients with benign and malignant pathology were assessed.A total of 916 patients were identified who underwent PN between 2007 and 2015, including 129 (14.1%) patients with a final diagnosis of benign disease. The most common types of benign pathology were oncocytoma (n = 66, 51.2%), angiomyolipoma (n = 37, 28.7%), and complex cysts (n = 10, 7.8%). Low body mass index (BMI) [0.96 (0.92-0.99) p = 0.02], low R.E.N.A.L. score [0.86 (0.76-0.96) p = 0.007], and low preoperative creatinine [0.37 (0.14-0.91) p = 0.04] predicted benign histology in multivariate analysis. Tumor size was a significant predictor in additional modeling [0.81 (0.69-0.94) p = 0.008]. Patients with benign histology had significantly shorter operative times (p 0.001) and less estimated blood loss (p 0.001), and there was no difference in complication (p = 0.93) or blood transfusion (0.24) rates.In this study, the rate of benign pathology after PN for presumed RCC is 14.1%. BMI, R.E.N.A.L. score, and preoperative creatinine are predictive of benign histology, but the ability of different variables to predict benign lesions may be influenced by the distribution of benign tumor subtypes, reflecting potential unidentified selection bias.

Objectives To analyze clinicopathological features and survival of surgically treated patients with renal cell carcinoma (RCC)≥80 years of age in comparison with patients between the ages of 60 and 70 years. Materials and methods The data for 2,516 patients with a median follow-up of 57 months were retrieved from a multinational database (Collaborative Research on Renal Neoplasms Association [CORONA]), including data for 6,234 consecutive patients with RCC after radical or partial nephrectomy. Comparative analysis of clinicopathological features of 241 octogenarians (3.9% of the database) and 2,275 reference patients between the ages of 60 and 70 years (36.5%) was performed. Multivariable regression analysis adjusted for competing risks was applied to identify the effect of advanced age on cancer-specific mortality (CSM) and other-cause mortality (OCM). Furthermore, instrumental variable analysis was employed to reduce residual confounding by unmeasured parameters. Results Significantly more women were present (50% vs. 40%, P = 0.004), and significantly less often nephron-sparing surgery was performed in octogenarians compared with the reference group (11% vs. 20%, P P = 0.009). On multivariable analysis, higher CSM (hazard ratio = 1.48, P = 0.042) and OCM rates (hazard ratio = 4.32, P c -indices = 0.85 and 0.72, respectively). Integration of the variable age group in multivariable models significantly increased the predictive accuracy regarding OCM (6%, P Conclusions Octogenarian patients with RCC significantly differ in clinical features and display significantly higher CSM and OCM rates in comparison with their younger counterparts.

Objective To determine the incidence of symptomatic and ‘silent’ obstruction after ureteroscopic procedures. Patients and methods In all, 1980 patients underwent ureteroscopy for ureteric calculi in two large centres. The methods of disintegration, auxiliary procedures used and type of stenting were considered. Intraoperative complications, in addition to the size and site of the stone, were assessed in relation to postoperative obstruction. The mean (range) follow-up was 42 (12–68) months, with patients assessed after 3–6 months and yearly thereafter. The postoperative evaluation included an assessment of pain, renal ultrasonography, a plain abdominal film, intravenous urography, and a diuretic renal scan in some cases to confirm obstruction. Results The success rate of stone removal was 98.5%. The failures were related to the size of the stone (>2 cm; P 2 cm (4.4%), compared to three (0.17%) of 1746 patients with stones of 2 cm in the proximal ureter.