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Objective: The aim of the present study was to explore the utility of mathematically calculated tumor contact surface area (CSA), which has been introduced as a predictor of postoperative renal function, in patients who underwent partial nephrectomy (PN) for solitary renal mass at Siriraj Hospital -- Thailand's largest national tertiary referral center. Materials and Methods: The authors retrospectively reviewed all patients who underwent PN as the management of solitary renal mass from 2012 to 2017 at Siriraj Hospital, Bangkok, Thailand. Only patients who had available pre-operative imaging and serum creatinine before and after PN were included. CSA was calculated using the formula 2πrd, where r = tumor radius, and d = intraparenchymal depth of tumor from preoperative computed tomography or magnetic resonance imaging. Estimated glomerular filtration rate (eGFR) was estimated by Chronic Kidney Disease Epidemiology formula. Postoperative eGFR was based on the best serum creatinine level within a year after surgery. Spearman's correlation coefficient, univariate, and multivariate linear regression analyses were utilized to identify factors associated with percent eGFR change (PCE) after PN. Results: Of 67 patients, the mean age was 58.3+12.5 years and 43 (64.2%) were male. Median tumor size, R.E.N.A.L. score, and CSA was 2.8 cm (interquartile range [IQR]: 2.2 to 3.5), 7 (IQR: 6 to 9), and 16.1 cm2 (IQR: 9.8 to 23.8), respectively. Open PN was performed in 32 patients (47.8%), and minimally invasive PN was performed in 35 patients (52.2%). Median preoperative and postoperative eGFR was 77 (IQR: 53 to 89) and 70 (IQR: 53 to 87) ml/min/1.73 m2, respectively. Median absolute eGFR change (ACE) was 4.6 ml/ min/1.73 m2 (IQR: 0.0 to 12.1), and the median PCE was 4.6% (IQR: 0.0 to 4.6). CSA was found to be significantly correlated with R.E.N.A.L. score (r = 0.55, p<0.001); however, neither CSA nor R.E.N.A.L. score was significantly associated with ACE or PCE. Multivariate analysis showed that male gender (p = 0.02) and cardiovascular disease (p = 0.03) were significantly associated with PCE. Conclusion: Although calculated CSA from pre-operative imaging was feasible to predict postoperative renal function after PN, it failed to be associated with postoperative renal function in our study. Further study is needed to validate the utility of this technique. [ABSTRACT FROM AUTHOR]

Objective: To investigate the outcomes of retrograde intrarenal surgery (RIRS) for large renal calculi, and to identify factors that influence the stone-free rate after RIRS for renal stone burden greater than 2 centimeters. Materials and Methods: This retrospective chart review included patients who underwent RIRS for renal calculi greater than 2 centimeters in size during January 2015 to December 2016 at Siriraj Hospital Thailand's largest national tertiary referral center. Data were collected and compared between those having and not having residual stones greater than 2 cm in diameter. Results: The present study included 100 eligible cases. The most common site was at lower calyces (42%). The mean stone burden size was 31.43 mm (range: 20 to 140). The average operative time was 62 minutes (range: 20 to 150), and the mean hospital length of stay was 2.7 days (range: 1 to 22). The most common stone composition was calcium oxalate monohydrate (37%), followed by calcium phosphate (23%). The success rate was 84% and 94% after the 1st session and 2nd session of RIRS, respectively. The factors that were found to predict residual stone after RIRS were stone burden greater than 35 mm in size (odds ratio [OR]: 5.86, 95% confidence interval [CI]: 1.77 to 19.57; p = 0.004) and lower pole location (OR: 1.97, 95% CI: 1.039 to 3.742; p = 0.038). Sepsis was found in 6 patients, all of whom were successfully treated with intravenous antibiotic, except for one mortality in an immunocompromised patient. Conclusion: RIRS is a promising treatment option for renal calculi with large stone burden. Large kidney stones (>2 cm) can be treated with high success rate and low morbidity. The most significant predictors of residual calculi are stone burden more than 35 millimeters in size and lower pole location. [ABSTRACT FROM AUTHOR]

Purpose: Finite courses of androgen deprivation therapy (ADT) are often utilized in men undergoing treatment for prostate cancer. Previous evidence suggests that timing of testosterone (T) recovery can be variable after ADT. Recently, an oral gonadotropin releasing-hormone (GnRH) antagonist, relugolix, has demonstrated more rapid T recovery than injectable GnRH agonists such as leuprolide. In this study, we sought to evaluate patient characteristics associated with T recovery in patients undergoing ADT of defined duration., Materials and Methods: The Northwestern Enterprise Data Warehouse was queried for men with prostate cancer who completed a course of ADT and subsequently had a testosterone lab performed. Testosterone recovery was evaluated for levels that reached above castrate (T > 50 ng/dl), partial recovery (T > 150 ng/dl), and full recovery (T ≥ 300 ng/dl)., Results: 388 men who received finite courses of ADT were identified (348 receiving leuprolide, 36 receiving relugolix, and 4 receiving degarelix). In multivariable Cox regression analysis, men who were prescribed GnRH antagonists (HR = 3.74, CI = 2.53-5.53, P ≤ 0.001) and who were younger (HR for 1 year increase in age = 0.96, CI = 0.95-0.98, P < 0.001) were more likely to achieve partial recovery. In a subgroup analysis, men who received extended ADT courses (>12 months) with a GnRH agonist had lower rates of partial T recovery (HR = 0.58, CI = 0.41-0.81, P = 0.001)., Conclusion: T recovery after ADT is variable with roughly one sixth of men remaining castrate. GnRH antagonist use and younger age are associated with higher rates of T recovery after ADT. Longer ADT courses were associated with worse T recovery rates., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ashley E. Ross, Alicia K. Morgans, Edward Schaeffer reports a relationship with Astellas Pharma Inc that includes: consulting or advisory. Ashley E. Ross, Alicia K. Morgans reports a relationship with AstraZeneca that includes: consulting or advisory. Ashley E. Ross, Alicia K. Morgans reports a relationship with Bayer Corporation that includes: consulting or advisory. Alicia K. Morgans reports a relationship with AAA that includes: consulting or advisory. Ashley E. Ross reports a relationship with Blue Earth Diagnostics that includes: consulting or advisory. Ashley E. Ross reports a relationship with Boston Scientific Corporation that includes: consulting or advisory. Ashley E. Ross reports a relationship with BillionToOne that includes: consulting or advisory. Alicia K. Morgans reports a relationship with Curium that includes: consulting or advisory. Alicia K. Morgans reports a relationship with Exelixis Inc that includes: consulting or advisory. Ashley E. Ross, Alicia K. Morgans reports a relationship with Janssen Pharmaceuticals Inc that includes: consulting or advisory. Ashley E. Ross, Alicia K. Morgans reports a relationship with Lantheus Medical Imaging Inc that includes: consulting or advisory. Alicia K. Morgans reports a relationship with Merck that includes: consulting or advisory. Alicia K. Morgans reports a relationship with MacroGenics Inc that includes: consulting or advisory. Ashley E. Ross, Alicia K. Morgans, Edward Schaeffer reports a relationship with Pfizer that includes: consulting or advisory. Ashley E. Ross, Alicia K. Morgans reports a relationship with Sumitomo Pharma America Inc that includes: consulting or advisory. Alicia K. Morgans reports a relationship with Novartis Pharmaceuticals Corporation that includes: consulting or advisory. Alicia K. Morgans reports a relationship with Telix Pharmaceuticals Limited that includes: consulting or advisory. Ashley E. Ross reports a relationship with Veracyte Inc that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Declarations. Competing interests: The authors declare no competing interests.

The National Comprehensive Cancer Network (NCCN) very low risk (VLR) category for prostate cancer (PCa) represents clinically insignificant disease, and detection of VLR PCa contributes to overdiagnosis. Greater use of magnetic resonance imaging (MRI) and biomarkers before patient selection for prostate biopsy (PBx) reduces unnecessary biopsies and may reduce the diagnosis of clinically insignificant PCa. We tested a hypothesis that the proportion of VLR diagnoses has decreased with greater use of MRI-informed PBx using data from our 11-hospital system. From 2018 to 2023, 351/3197 (11%) men diagnosed with PCa met the NCCN VLR criteria. The proportion of VLR diagnoses did not change from 2018 to 2023 (p = 0.8) despite an increase in the use of MRI-informed PBx (from 49% to 82%; p < 0.001). Of patients who underwent combined systematic and targeted PBx and were diagnosed with VLR disease, cancer was found in systematic PBx regions in 79% of cases and in targeted PBx regions in 31% of cases. When performing both systematic and targeted PBx, prebiopsy MRI-based risk calculators could limit VLR diagnosis by 41% using a risk threshold of >5% for Gleason grade group ≥3 PCa to recommend biopsy; the reduction would be 77% if performing targeted PBx only. These findings suggest that VLR disease continues to account for a significant minority of PCa diagnoses and could be limited by targeted PBx and risk stratification calculators. PATIENT SUMMARY: We looked at recent trends for the diagnosis of very low-risk (VLR) prostate cancer. We found that VLR cancer still seems to be frequently diagnosed despite the use of MRI (magnetic resonance imaging) scans before biopsy. The use of risk calculators to identify men who could avoid biopsy and/or biopsy only for lesions that are visible on MRI could reduce the overdiagnosis of VLR prostate cancer., (Copyright © 2024 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objectives: The objective of this study is to evaluate preoperative factors associated with cardiopulmonary bypass (CPB) utilization and outcomes for patients with renal cell carcinoma (RCC) and tumour thrombus (TT). Radical nephrectomy with thrombectomy is a standard treatment for patients with RCC and associated TT. Morbidity and mortality rates tend to correlate with aggressiveness of tumour and TT level., Methods: Patients undergoing radical nephrectomy with thrombectomy (2006-2023) were retrospectively identified. Inclusion criteria included RCC histology and preoperative imaging available for thrombus-level categorization based on the Mayo Clinic grading system. Logistic regression assessed predictors for utilizing CPB, and Cox regression identified factors associated with survival., Results: A total of 72 patients with RCC and associated TT were identified. The median age was 67 years. RCC-related symptoms were present in 83%, and 28% had Levels 3 and 4 thrombi. Eleven patients (15.3%) had undergone neoadjuvant therapy, and 81% had clear-cell RCC. CPB was utilized in eight (11.1%) cases. The median tumour size was 10.5 cm. Metastatic disease was greater in the CPB cohort (75% vs. 28%, p  = 0.008). All cases performed on CPB were Levels 3 and 4 thrombi (100% vs. 19% in the non-CPB group, p  < 0.001). CPB cases had significantly longer operative time, and hospital stays and rates of Clavien ≥ 3 complications. On multivariate analysis, metastatic disease was a predictor of CPB utilization. Median survival was 74 and 25 months in the non-CPB and CPB cohorts, respectively ( p  = 0.01). Pulmonary disease and metastatic disease with CPB utilization were significantly associated with worse survival on multivariate analysis., Conclusions: Surgical extirpation of kidney tumours with associated TT remains the standard of care among patients with locally advanced RCC. CPB can be utilized to increase the feasibility of resection for high-level thrombi. Preoperative planning and cooperation among surgical teams are key given the perioperative morbidity and mortality., Competing Interests: None of the authors have any disclosures or conflict of interest to report., (© 2025 The Author(s). BJUI Compass published by John Wiley & Sons Ltd on behalf of BJU International Company.)

Background and Objectives: Partial (PN)/radical (RN) nephrectomy is the standard treatment for localized renal-cell carcinoma (RCC). The potential risks of these procedures are concerns for the elderly. We evaluated perioperative outcomes/survival for patients aged ≥ 75 years with localized RCC who underwent PN, RN, or thermal ablation (TA)., Methods: Localized RCC patients undergoing PN/RN/TA (2000-2023) were retrospectively reviewed. Logistic-regression assessed factors associated with major complications. Kaplan-Meier estimated survival., Results: A total of 278 patients (≥ 75 years) with RCC who received intervention (107RN, 101PN, and 70TA) were identified. Median age was 78 years. PN patients were younger than other cohorts (77 vs. 79, p = 0.006). Patients with cancer comorbidities underwent TA than PN/RN (93% vs. 88%/76%, respectively). Median tumor size was 4.0, 3.0, and 2.6 cm in RN, PN, and TA cohorts, respectively. RN patients had more complex masses compared to other cohorts (9 vs. 7, p < 0.001). Postoperative complications were significantly greater among PN patients (p = 0.03), but there was no significant difference in Clavien ≥ 3 complications. Peripheral vascular disease (PVD) was associated with Clavien ≥ 3 complications on multivariable analysis (p = 0.03). RN was performed at a stable rate while PN decreased in favor of TA. There was no significant difference in RCC-/non-RCC-specific survival among treatment modalities., Conclusions: It is important to make informed decisions about treating RCC in the elderly to reduce morbidity/mortality. PVD could be a determining factor favoring TA for amenable tumors., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

This study aims to determine the prevalence of perioperative PE and outcomes in patients with RCC scheduled for nephrectomy. A total of 418 patients were included in this single-center, observational study. Three hundred patients with RCC were retrospectively reviewed between 2016 and 2020, and the remaining patients were prospectively collected between 2020 and 2022 to minimize the effect of the long-time span. Patients with incomplete medical data and those who refused to participate were excluded. The primary outcome was the prevalence of perioperative PE. Secondary outcomes were associated factors, method of PE prophylaxis, rate of intraoperative transesophageal echocardiography (TEE) utilization, and 30-day mortality. The prevalence of perioperative PE was 1.9 % and most commonly occurred during the postoperative period (75 %). The prevalence rose to 7.5 % in patients with tumor thrombus. Significant factors related to PE included smoking (OR 6.78, 95 % CI 1.13-40.56) and change in tumor thrombus stage (OR 21.55, 95 % CI 3.69-125.71). There was no difference in the rate or method of PE prophylaxis between the two groups. Of the patients, 2.9 % underwent intraoperative TEE monitoring and 0.2 % received rescue TEE. Pneumonia and acute respiratory distress syndrome were significantly correlated with PE ( P  < 0.001 and P  = 0.03, respectively). Finally, there was no significant difference in 30-day mortality ( P  = 0.07). The overall prevalence of PE in patients with RCC scheduled for nephrectomy was rare but more likely to occur in those with tumor thrombus., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Objective: To compare long-term incidence rate of chronic kidney disease (CKD) in patients after tumor nephrectomy (TN) and donor nephrectomy (DN) and to evaluate risk factors for developing CKD., Materials and Methods: Data from 1048 patients who performed TN (552) and DN (496) between 2000 and 2018 at Siriraj hospital were retrospectively analyzed. We obtained 106 patients for each group after using a 1:1 propensity score matching by age and preoperative glomerular filtration rate (GFR). The incidence rate of CKD and risk factors for CKD stage ≥3 were evaluated., Results: There were no differences in incidence of CKD between TN (26.4 %) and DN group (24.5 %) with median follow-up time of 4.95 and 6.05 years (p = 0.308). There were no differences in mean GFR postoperatively at up to ten years follow-up (p = 0.378). The GFR at last follow-up was 71.15 and 68.1 ml/min/1.73 m 2 in TN and DN groups (p = 0.172). The TN showed more proteinuria than DN group but not for postoperative hypertension. The multivariate analysis showed age 47 years (p = 0.012) and preoperative GFR 100 (p = 0.001) as a risk factor for developing CKD after nephrectomy but not for type for nephrectomy (p = 0.753)., Conclusion: The risk of developing CKD in patients after tumor nephrectomy was the same as in living kidney donors who were matched by age and preoperative GFR. Age over 47 years and preoperative GFR <100 of patients should be considered risk factors for developing CKD in patients choosing nephrectomy as the treatment of choice., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Objective: This study aims to evaluate the prevalence of early postoperative complications of radical cystectomy, using standardized reporting methodology to assess perioperative characteristics and determine risk factors for major complications., Materials and Methods: A retrospective study included 254 consecutive bladder cancer patients undergoing RC between 2012 and 2020 at a urological cancer referral center. Postoperative complications within 30 days were recorded and graded according to the Clavien-Dindo classification (CDC). The study examined risk factors, including novel inflammatory-nutrition biomarkers and perioperative serum chloride., Results: Total complications were observed in 135 (53 %). Of these, 47 (18.5 %) were high grade (CDC ≥ 3). Wound dehiscence was the most common complication, occurring in 14 (5.5 %) patients. Independent risk factors for major complications included an age-adjusted Charlson comorbidity index (ACCI) > 4 and thrombocytopenia (odds ratio [OR] 3.67 and OR 8.69). Preoperative platelet counts < 220,000/μL and albumin < 3 mg/dL were independent risk factors for wound dehiscence (OR 3.91 and OR 4.72). Additionally, postoperative hypochloremia was a risk factor for major complications (OR 13.71), while novel serum biomarkers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory response index (SIRI), and prognostic nutritional index (PNI) were not associated with early major complications., Conclusion: Patients who have multiple comorbidities are at a greater risk of developing major complications after undergoing RC. Our result suggests that preoperative platelet counts and serum albumin levels are associated with wound dehiscence., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

The number of people living with HIV infection has been increasing globally. Administration of antiretroviral therapy is effective in controlling the infection for most patients and, as a consequence, people living with HIV (PLWH) now often have a long life expectancy. However, their risk of developing cancer - most notably virus-related cancers - has been increasing. To date, few studies have assessed the risk of genitourinary cancers in PLWH, and robust scientific data on their treatment-related outcomes are lacking. Previous studies have noted that PLWH are at a reduced risk of prostate cancer; however, low adoption and/or availability of prostate cancer screening among these patients might be confounding the validity of this finding. In genitourinary cancers, advanced stage at diagnosis and reduced cancer-specific mortality have been reported in PLWH. These data likely reflect, at least in part, the inequity of health care access for PLWH. Notably, systemic chemotherapy and/or radiotherapy could decrease total CD4 + cell counts, which could, therefore, increase the risk of morbidity and mortality from cancer treatments in PLWH. Immune checkpoint inhibitors have become the therapeutic backbone for many advanced malignancies in the general population; however, most studies validating their efficacy have excluded PLWH owing to concerns of severe adverse effects from immune checkpoint inhibitors themselves and/or related to their immunosuppressed status. To our knowledge, no genitourinary cancer survivorship programme exists that specifically caters to the needs of PLWH. By including PLWH in ongoing cancer trials, we can gain invaluable insights that will help to improve cancer care specifically for PLWH., (© 2024. Springer Nature Limited.)

Objective: To automate the generation of three validated nephrometry scoring systems on preoperative computerised tomography (CT) scans by developing artificial intelligence (AI)-based image processing methods. Subsequently, we aimed to evaluate the ability of these scores to predict meaningful pathological and perioperative outcomes., Patients and Methods: A total of 300 patients with preoperative CT with early arterial contrast phase were identified from a cohort of 544 consecutive patients undergoing surgical extirpation for suspected renal cancer. A deep neural network approach was used to automatically segment kidneys and tumours, and then geometric algorithms were used to measure the components of the concordance index (C-Index), Preoperative Aspects and Dimensions Used for an Anatomical classification of renal tumours (PADUA), and tumour contact surface area (CSA) nephrometry scores. Human scores were independently calculated by medical personnel blinded to the AI scores. AI and human score agreement was assessed using linear regression and predictive abilities for meaningful outcomes were assessed using logistic regression and receiver operating characteristic curve analyses., Results: The median (interquartile range) age was 60 (51-68) years, and 40% were female. The median tumour size was 4.2 cm and 91.3% had malignant tumours. In all, 27% of the tumours were high stage, 37% high grade, and 63% of the patients underwent partial nephrectomy. There was significant agreement between human and AI scores on linear regression analyses (R ranged from 0.574 to 0.828, all P < 0.001). The AI-generated scores were equivalent or superior to human-generated scores for all examined outcomes including high-grade histology, high-stage tumour, indolent tumour, pathological tumour necrosis, and radical nephrectomy (vs partial nephrectomy) surgical approach., Conclusions: Fully automated AI-generated C-Index, PADUA, and tumour CSA nephrometry scores are similar to human-generated scores and predict a wide variety of meaningful outcomes. Once validated, our results suggest that AI-generated nephrometry scores could be delivered automatically from a preoperative CT scan to a clinician and patient at the point of care to aid in decision making., (© 2024 BJU International.)

Objective: The role of tumor thrombus as a predictor of survival in patients with renal cell carcinoma (RCC) is controversial. This study aims to evaluate surgical and oncological outcomes after surgery in RCC with inferior vena cava (IVC) tumor thrombus patients., Materials and Methods: A total of 58 patients (2002-2019) underwent radical nephrectomy and IVC thrombectomy at our institute, were retrospectively reviewed. Kaplan-Meier analysis was utilized to compare survival benefits between cohorts and Cox-regression to evaluate potential predictors of patient survival., Results: There were 5(8.6%), 21(36.2%), 23(39.7%) and 9 (15.5%) patients with tumor thrombus level I, II, III and IV respectively. The major complications (Clavien 3-5) were observed in 15 patients (25.8%) and 12 patients (80%) were patients with high thrombus level (III-IV). There was 9%mortality (5patients): 2 intraoperatively and 3 postoperatively. Median follow-up was 15 months (IQR:5-41). Two-year overall survival (OS) was 80% and 75% in all patients and pN0M0 cohort, respectively. There was significant difference in OS among each IVC thrombus level cohort (p < 0.02). Two-year OS of metastatic RCC patients was 67% and not significantly different when compared to non-metastatic cohort (p = 0.12). On multivariate analysis, only sarcomatoid dedifferentiation was associated with OS(p = 0.04). Disease-free survival was not significantly different among thrombus-level cohorts (p = 0.65)., Conclusions: Our study suggested that surgical treatment for RCC with IVC thrombus provided substantial OS outcomes. Although survival was significantly reduced with higher IVC thrombus level cohort, the level of thrombus itself was not an independent factor. Only sarcomatoid dedifferentiation was a predictor for reduced OS after radical nephrectomy and tumor thrombectomy. Meticulous patient selection and prompt counselling are substantial step for the operation., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Introduction: Disposable (single-use) flexible ureteroscopes are alternatives to reusable ureteroscopes. With their superior surgical efficacy and safety in the presence of upper urinary calculi, disposable ureteroscopes aim to overcome the main limitations of conventional reusable ureteroscopes. However, studies on the performance of the most recently developed models of single-use flexible ureteroscopes are scarce. This study aimed to compare the in vitro performance of several recently introduced, single-use, flexible ureteroscopes., Methods: Five disposable flexible ureteroscopes were tested in vitro to evaluate their mechanical and optical characteristics. To this end, their degrees of deflection, irrigation flow rates, and image qualities were investigated. The models examined were Innovex US31-B12, OTU-100RR, Redpine RP-U-C12, Sciavita SUV-2A-B, and Seplou URS3016E. Their performance was also compared with that of a reusable flexible ureteroscope, Olympus URV-F., Results: The OTU device had the highest degrees of deflection and the smallest loop diameter of the disposable ureteroscopes. The single-use ureteroscopes had identical image resolutions at a distance of 1 cm. The Innovex and Redpine devices had the best color representation., Conclusions: Of the tested disposable ureteroscopes, the OTU device had the best mechanical attributes, given its small loop diameter, high deflection angles, and low irrigation flow loss. As to their optical properties, the resolutions of all 5 single-use models were identical at an image distance of 1 cm., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Objective: To determine whether we can surpass the traditional R.E.N.A.L. nephrometry score (H-score) prediction ability of pathologic outcomes by creating artificial intelligence (AI)-generated R.E.N.A.L.+ score (AI+ score) with continuous rather than ordinal components. We also assessed the AI+ score components' relative importance with respect to outcome odds., Methods: This is a retrospective study of 300 consecutive patients with preoperative computed tomography scans showing suspected renal cancer at a single institution from 2010 to 2018. H-score was tabulated by three trained medical personnel. Deep neural network approach automatically generated kidney segmentation masks of parenchyma and tumor. Geometric algorithms were used to automatically estimate score components as ordinal and continuous variables. Multivariate logistic regression of continuous R.E.N.A.L. components was used to generate AI+ score. Predictive utility was compared between AI+, AI, and H-scores for variables of interest, and AI+ score components' relative importance was assessed., Results: Median age was 60years (interquartile range 51-68), and 40% were female. Median tumor size was 4.2 cm (2.6-6.12), and 92% were malignant, including 27%, 37%, and 23% with high-stage, high-grade, and necrosis, respectively. AI+ score demonstrated superior predictive ability over AI and H-scores for predicting malignancy (area under the curve [AUC] 0.69 vs 0.67 vs 0.64, respectively), high stage (AUC 0.82 vs 0.65 vs 0.71, respectively), high grade (AUC 0.78 vs 0.65 vs 0.65, respectively), pathologic tumor necrosis (AUC 0.81 vs 0.72 vs 0.74, respectively), and partial nephrectomy approach (AUC 0.88 vs 0.74 vs 0.79, respectively). Of AI+ score components, the maximal tumor diameter ("R") was the most important outcomes predictor., Conclusion: AI+ score was superior to AI-score and H-score in predicting oncologic outcomes. Time-efficient AI+ score can be used at the point of care, surpassing validated clinical scoring systems., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To analyze predictors, extent and functional implications associated with renal parenchymal volume replacement (PVR) by renal cell carcinoma (RCC) prior to intervention. This phenomenon is well-recognized yet not adequately studied, and, if severe, can influence management., Materials and Methods: A retrospective review was performed of partial nephrectomy (PN) and radical nephrectomy (RN) patients with available preoperative nuclear-renal-scan and imaging demonstrating solitary RCC with normal contralateral kidney. Normal renal parenchymal volume of each kidney was measured by free-hand scripting from preoperative axial images. Primary endpoint was percent PVR which was estimated assuming that the contralateral-kidney serves as a control: PVR = (volume contralateral kidney - volume ipsilateral kidney) normalized by volume contralateral kidney. Multivariable linear-regression analysis assessed factors associated with preoperative PVR. Further analysis evaluated the functional effect of PVR prior to surgery., Results: 146 PN and 136 RN patients with necessary studies were analyzed. For RN, the median PVR was 15% and a quarter of patients had PVR ≥27%. In contrast, PVR was negligible in PN patients for whom median preoperative parenchymal volumes were nearly identical in the ipsilateral/contralateral kidneys (179/180cc, respectively). PVR inversely correlated with preoperative renal function in the ipsilateral kidney (P <.01). Tumor-size (P <.01), stage (P = .03), and endophytic properties (P = .03) associated with PVR on multivariable-analysis., Conclusion: Our data suggest that substantial replacement of normal parenchyma by RCC occurs in many patients selected for RN and can contribute to preexisting renal-insufficiency. PVR prior to intervention is mainly driven by tumor characteristics in RN patients, but is negligible in most PN patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The prevalence of infiltrative renal masses (IRMs) and fidelity of documentation of infiltrative features remain unclear., Objective: To investigate the prevalence/significance of IRMs and assess whether infiltrative features were documented preoperatively., Design, Setting, and Participants: A total of 522 patients with renal tumors managed with partial/radical nephrectomy (2012-2014) whose pathology demonstrated locally advanced and/or aggressive histology were analyzed. Preoperative computed tomography/magnetic resonance imaging was retrospectively/independently reviewed by two radiologists. IRMs were required to have a poorly defined interface with parenchyma and nonelliptical shape in one or more distinct/unequivocal areas. Infiltrative features were defined as extensive or focal., Intervention: Partial/radical nephrectomy., Outcome Measurements and Statistical Analysis: Cancer-specific mortality (CSM) was estimated using cumulative-incidence analysis. Significant and independent predictors of CSM were evaluated using Cox proportional hazard analysis., Results and Limitations: Median tumor size was 6.9cm; renal cell carcinomas (RCCs) predominated (92%). Image review confirmed 133 IRMs (25%), including 103 RCCs; 59 had sarcomatoid or poorly differentiated features. IRMs were larger and more often symptomatic compared than non-IRMs, and disseminated disease was also more common for IRMs (all p<0.001). Overall, 109 IRMs were imaged at our center; 42 were documented as IRMs in preoperative radiology reports, while infiltrative features were not documented in 67 (61%). Only four (6%) of these 67 were documented as infiltrative by the surgical team. Infiltrative features were more often focal in undocumented IRMs. On multivariable analysis, infiltrative features, disseminated disease, and non-RCC histology were independent predictors of CSM (hazard ratio or HR [95% confidence interval {CI}]=1.73 [1.21-2.47], 2.98 [2.10-4.23], and 2.79 [1.86-4.62], respectively). Among IRMs, extensive infiltrative features and disseminated disease were associated with CSM (HR [95% CI]=1.98 [1.27-3.07] and 2.35 [1.52-3.63], respectively), while documentation status failed to show an association. Excluding patients with disseminated disease or residual cancer after surgery, recurrence rates were 62% for IRMs versus 22% for non-IRMs (p<0.001), and there was again no significant difference between documented and undocumented IRMs (p=0.36). Limitations include a retrospective design., Conclusions: Twenty-five percent of locally advanced/histologically aggressive renal tumors exhibited infiltrative features, although many were not documented as IRMs. Among this high-risk surgical population, infiltrative features were independent predictors of CSM, irrespective of whether they were documented or not. Our data suggest that infiltrative features should be assessed and documented routinely during evaluation of renal masses., Patient Summary: Infiltrative renal masses may be more common than previously appreciated, although many were not documented as infiltrative during preoperative evaluation. Our data suggest that infiltrative features have a strong impact on prognosis and should be assessed and documented routinely during radiologic and clinical evaluation of renal masses., (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

The management of metastatic renal cell carcinoma (mRCC) continues to be a therapeutic challenge; however, the options for systemic therapy in this setting have exploded over the past 20 years. From the advent of toxic cytokine therapy to the subsequent discovery of targeted therapy (TT) and immune checkpoint inhibitors, the landscape of viable treatment options continues to progress. With the arrival of cytokine therapy, two randomized trials demonstrated a survival benefit for upfront cytoreductive nephrectomy (CN) plus interferon therapy and this approach became the standard for surgical candidates. However, it was difficult to establish the role and the timing of CN with the subsequent advent of TT, just a few years later. More recently, two randomized phase III studies completed in the TT era questioned the use of CN and brought to light the role of risk stratification while selecting patients for CN. Careful identification of the mRCC patients who are likely to have a rapid progression of the disease is essential, as these patients need prompt systemic therapy. With the continued advancement of systemic therapy using the immune checkpoint inhibitors as a first line therapy, the role of CN will continue to evolve., Competing Interests: Conflicts of Interest: There are no conflicts of interest., (Copyright: © 2021 Indian Journal of Urology.)

Background: Postchemotherapy retroperitoneal lymphadenectomy (PC-RPLND) is an essential, yet potentially morbid, therapy for the management of patients with advanced germ cell tumors. In the current study, the authors sought to define the complication profile of PC-RPLND using validated grading systems for intraoperative adverse events (iAEs) and early postoperative complications., Methods: Between 2000 and 2018, all patients who underwent PC-RPLND were analyzed for iAEs and early postoperative complications using the Kaafarani and Clavien-Dindo classifications, respectively. Logistic regression models were conducted to assess patient and tumor factors associated with iAEs and postoperative complications., Results: Of the 453 patients identified, 115 patients (25%) and 252 patients (56%), respectively, experienced an iAE and postoperative complication. Major iAEs (grade ≥3) were observed in 15 patients (3%) and major postoperative complications (grade ≥3) were noted in 80 patients (18%). The most common iAE was vascular injury (112 of 132 events; 85%), which occurred in 92 patients (20%), and the most frequent postoperative complication was ileus, which occurred in 121 patients (27%). Original and postchemotherapy retroperitoneal mass size, nonretroperitoneal metastases, intermediate and/or poor International Germ Cell Cancer Collaborative Group classification, previous RPLND, elevated tumor markers at the time of RPLND, and anticipated adjuvant surgical procedures increased the risk of both iAEs and postoperative complications. Patients who experienced an iAE were significantly more likely to experience a postoperative complication (odds ratio, 2.50; 95% confidence interval, 1.58-3.97 [P < .001])., Conclusions: In what to the authors' knowledge is the first analysis of PC-RPLND using validated classifications for both iAEs and postoperative complications, advanced disease and surgical complexity significantly increased the risks of major iAEs and postoperative complications. Standardized reporting of adverse perioperative events allows providers and patients to appreciate the consequences of PC-RPLND during counseling and decision making., (© 2020 American Cancer Society.)

Purpose: Loss of renal function remains a major limitation of radical nephrectomy. The extent of renal functional compensation by the preserved kidney after radical nephrectomy has not been adequately studied in this elderly population with comorbidities., Materials and Methods: A total of 273 patients treated with radical nephrectomy without end stage renal disease with available preoperative nuclear renal scans were included in the analysis. Renal functional compensation was defined as percent change in estimated glomerular filtration rate of the preserved kidney after radical nephrectomy. Estimated glomerular filtration rate was calculated by the Chronic Kidney Disease-Epidemiology Collaboration formula up to 5 years postoperatively. Preoperative/postoperative parenchymal volumes of the preserved kidney were measured from cross-sectional imaging. Multiple regression was used to identify predictive factors for renal functional compensation., Results: Median age was 67 years and 67% of the patients were male. Overall 70% had hypertension, 26% diabetes and 37% preexisting chronic kidney disease. Locally advanced (T3a or greater) tumors were found in 53% of cases. Renal functional compensation was observed at 2 weeks (median 10%) and increased during the first 3 months (median 26%) after radical nephrectomy. Functional stability was then observed to 5 years. Renal parenchymal volume increased a median of 10% at 3 to 12 months but in addition, the functional efficiency per unit of parenchymal volume also increased 8% (estimated glomerular filtration rate units/cm 3 of parenchyma was 0.236 postoperatively vs 0.208 preoperatively, p=0.004). Age (-0.85, p <0.01), global preoperative estimated glomerular filtration rate (-0.28, p <0.01) and split renal function of the removed kidney (0.61, p <0.01) were independent predictors of renal functional compensation., Conclusions: Percent renal functional compensation after radical nephrectomy is greater in younger patients, when preoperative estimated glomerular filtration rate is lower and when the removed kidney has more robust function. Increases in measurable parenchymal mass and functional efficiency contribute substantially to renal functional compensation.

Objective: To analyze the full spectrum of patients presenting with radiologically-identified infiltrative renal masses (IRMs), including those managed surgically or otherwise, with focus on clinical presentation/prognosis., Methods: All 280 patients presenting with radiologically-identified renal mass with infiltrative features (2008-2017) were retrospectively reviewed. Poorly-defined interface between tumor and parenchyma and irregular shape (nonelliptical) in one or more distinct/unequivocal areas were required for classification as IRM. IRM was confirmed in 265 and clinical characteristics and outcomes were assessed., Results: Median age/tumor size were 65-years/6.9 cm, respectively, and 225 patients (85%) were R.E.N.A.L. = 10-12. Overall, 181 patients (68%) presented symptomatically, locally-advanced cancer (cT3-T4) was observed in 176 (66%) and disseminated disease and/or lymphadenopathy (>2 cm) in 181(68%). Clinical/radiographic findings were suggestive of etiology and could direct evaluation, but were nonspecific for definitive diagnosis. Renal-mass biopsy was performed in 103 patients and diagnostic in 97 (94%). Renal surgery was only performed in 82 patients (31%) and partial nephrectomy in 3 (1.1%). Overall, 72 patients (27%) received systemic chemotherapy and 59 (22%) targeted therapy. Final-diagnosis was renal cell carcinoma in 94 patients (35%), including 49 with highly-aggressive histology (sarcomatoid/rhabdoid/collecting-duct/medullary/unclassified). High-grade urothelial-carcinoma was found in 70 (26%), and lymphoma/metastatic cancer in 26 (10%)/25 (9%), respectively. Overall, 153 patients (58%) died; 138 (52%) cancer-related at median of 5 months. The majority of patients with renal cell carcinoma, urothelial-carcinoma, and renal metastasis died, almost exclusively cancer-related, at medians of 8, 3, and 2 months, respectively., Conclusion: Our series includes the full spectrum of IRMs and confirms predominance of symptomatic, poorly-differentiated, highly-lethal malignancies. Our study highlights the overriding importance of identifying infiltrative features, a simple radiologic diagnosis, during assessment of renal masses., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Retrospective studies suggest that partial nephrectomy provides improved survival compared to radical nephrectomy even when performed electively. However, selection bias may contribute. We evaluated factors associated with nonrenal cancer related mortality after partial and radical nephrectomy in patients with a preoperative glomerular filtration rate of 60 ml/minute/1.73 m 2 or greater., Materials and Methods: We retrospectively evaluated the records of 3,133 patients with a preoperative glomerular filtration rate of 60 ml/minute/1.73 m 2 or greater who underwent partial or radical nephrectomy. Nonrenal cancer related mortality was analyzed by the Kaplan-Meier test based on procedure and functional parameters, including the new baseline glomerular filtration rate. We used the Cox proportional hazards model to assess factors associated with nonrenal cancer related mortality among patients with a new baseline rate of 45 ml/minute/1.73 m 2 or greater., Results: Overall median age was 59 years and the median preoperative glomerular filtration rate was 85 ml/minute/1.73 m 2 . The new baseline glomerular filtration rate was 80 and 63 ml/minute/1.73 m 2 and 10-year nonrenal cancer related mortality was 11.3% and 17.7% after partial and radical nephrectomy, respectively (each p <0.001). Median followup was 9.3 years. Nonrenal cancer related mortality was similar in all patients with a new baseline glomerular filtration rate of 45 ml/minute/1.73 m 2 or greater (p = 0.26). However, it increased 50% or more in the 290 patients with a new baseline below this level (p = 0.001). In patients with a new baseline greater than 45 ml/minute/1.73 m 2 10-year nonrenal cancer related mortality was still substantially improved after partial nephrectomy (10.6% vs 16.3%, p <0.001). In this population age, gender and partial vs radical nephrectomy were associated with nonrenal cancer related mortality on multivariable analysis (all p ≤0.001). In contrast, the increased new baseline glomerular filtration rate, as seen for partial nephrectomy, was not associated with reduced nonrenal cancer related mortality., Conclusions: In patients with a glomerular filtration rate of 60 ml/minute/1.73 m 2 or greater who undergo partial or radical nephrectomy our data suggest that treatment should achieve a new baseline of 45 ml/minute/1.73 m 2 or greater if feasible. Partial nephrectomy should be prioritized if needed to accomplish this. In patients with a new baseline rate of 45 ml/minute/1.73 m 2 or greater partial nephrectomy was associated with improved survival. However, the functional dividend, namely the increased new baseline rate, failed to correlate, suggesting that selection bias may also impact outcomes.

Purpose: The percent of preserved parenchymal mass is the primary determinant of functional outcomes after partial nephrectomy. Accurate methods to predict the percent of preserved parenchymal mass based on preoperative imaging could facilitate patient counseling., Materials and Methods: We evaluated the records of 428 patients who had undergone partial nephrectomy and the studies necessary to assess preserved ipsilateral parenchymal mass and function. Preoperative and postoperative ipsilateral parenchymal volumes were measured from contrast enhanced computerized tomography less than 2 months before and 3 to 12 months after partial nephrectomy and the actual percent of preserved parenchymal mass was determined. The ipsilateral percent of preserved parenchymal mass and the final global glomerular filtration rate were estimated based on preoperative imaging using subjective estimation, quantitative estimation, or estimation derived from the contact surface area or the R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior and location relative to polar lines) score., Results: Median tumor diameter was 3.5 cm, median contact surface area was 24 cm 2 and the median R.E.N.A.L. score was 8. The median actual ipsilateral percent of preserved parenchymal mass was 84% and the preserved percent of the global glomerular filtration rate was 89%. The median estimated ipsilateral percent of preserved parenchymal mass was 85%, 87%, 88% and 83% based on subjective estimation, quantitative estimation, contact surface area and the R.E.N.A.L. score, respectively. Correlations between the actual and the estimated percent of preserved parenchymal mass were relatively weak in all instances (all r ≤0.46). Prediction of the final global glomerular filtration rate was strong for all 4 methods (all r = 0.91). However, a similarly strong correlation was obtained when presuming that 89% of the preoperative global glomerular filtration rate would be saved in each case (r = 0.91). On multivariable analyses a solitary kidney, the preoperative glomerular filtration rate and various estimates of the percent of preserved parenchymal mass were significantly associated with the final global glomerular filtration rate. However, the preoperative glomerular filtration rate proved to be the strongest predictor. It had more than a tenfold impact compared to the estimated percent of preserved parenchymal mass or a solitary kidney., Conclusions: Currently available methods to estimate the percent of preserved parenchymal mass have important limitations. The final global glomerular filtration rate, which is the most important functional outcome, could be predicted fairly accurately by all tested methods. However, none of them were better than simply presuming that 89% of function would be saved due to strong anchoring to the preoperative glomerular filtration rate.

Purpose: To evaluate indications/outcomes for open partial nephrectomy (OPN) when non-flank approaches are required, with comparison to patients managed with the flank approach. Outcomes with a non-flank approach are presumed less favorable yet there have been no previous reports on this topic., Methods: 2747 OPNs were performed (1999-2015) and 76 (2.8%) required a non-flank approach. We also reviewed all traditional flank OPNs performed during odd years in this timeframe yielding 1467 patients for comparison., Results: Overall, median tumor size was 3.5 cm and 274 patients (18%) had a solitary kidney. Non-flank patients were younger, and tumor size and clinical/pathologic stage were significantly increased for this cohort, but the groups were otherwise comparable. Indications for non-flank OPN included large tumor size/locally advanced disease (n = 21), need for simultaneous surgery (n = 25), previous flank incision or failed thermoablation (n = 13), or congenital/vascular abnormalities (n = 9). The most common non-flank approach was anterior subcostal (n = 39, 51%). Operative times, estimated blood loss, positive margins, and functional decline were all modestly increased for non-flank patients. Intraoperative and genitourinary complications were more common in non-flank patients (p < 0.05), although all were manageable, typically with conservative measures. There were no mortalities among non-flank patients and none required long-term dialysis., Conclusions: Our series, the first to address this topic, suggests that outcomes with non-flank OPN are generally less advantageous likely reflecting increased tumor/operative complexity. However, complications in this challenging patient population are manageable and final dispositions are generally favorable. Our findings should be useful for counseling regarding potential outcomes when a non-flank incision is required.

Background: Percentage parenchymal mass preserved (PPMP) is a key determinant of functional outcomes after partial nephrectomy (PN); however, predictors of PPMP have not been defined., Objective: To provide a comprehensive analysis of the functional impact of and potential predictive factors for PPMP., Design, Setting, and Participants: We analyzed data for 464 patients managed with PN at our center with necessary studies to determine vascularized parenchymal mass and function preserved within the operated kidney. PPMP was measured from computed tomography scans <2 mo before and 3-12 mo after PN., Intervention: PN., Outcome Measurements/statistical Analysis: Recovery from ischemia was defined as percentage ipsilateral glomerular filtration rate (GFR) preserved normalized by PPMP. We used Pearson correlation to evaluate the relationships between GFR preserved and PPMP. Multivariable logistic regression was used to assess predictors of PPMP., Result and Limitations: Ninety-six patients (21%) had a solitary kidney. The median tumor size and RENAL score were 3.5cm and 8, respectively. Cold/warm ischemia were utilized in 183/281 patients for which the median ischemia time were 28/20min. The median preoperative and postoperative vascularized parenchymal mass in the operated kidney were 194 and 157cm 3 , respectively, resulting in median PPMP of 84%. GFR preservation correlated strongly with PPMP (r=0.64; p<0.001). Recovery from ischemia was suboptimal (<80%) in 71 patients (15%), while suboptimal PPMP (<80%) was a more common adverse event, occurring in 160 patients (34%; p<0.001). Multivariable analysis demonstrated that greater tumor size and complexity were associated with lower PPMP (p≤0.04), while solitary kidney and hypothermia were associated with higher PPMP (p<0.001). Longer ischemia time was also associated with lower PPMP (p=0.003), probably reflecting the complexity of the surgery. Limitations include the retrospective design., Conclusion: PPMP correlates strongly with functional outcomes after PN, and lower PPMP is the most common and important source of functional decline after PN. Larger tumors, greater tumor complexity, and prolonged ischemia time were associated with lower PPMP, while PPMP tended to be greater for solitary kidneys, confirming that PPMP is a modifiable factor., Patient Summary: Kidney function after partial nephrectomy primarily depends on the amount of vascularized kidney preserved by the procedure. Lower recovery of function is seen when operating on larger tumors in unfavorable locations, but preservation of the parenchymal mass can be improved when truly necessary, such as when operating on a tumor in a solitary kidney., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: Acute kidney injury often leads to chronic kidney disease in the general population. The long-term functional impact of acute kidney injury observed after partial nephrectomy has not been adequately studied., Materials and Methods: From 2004 to 2014 necessary studies for analysis were available for 90 solitary kidneys managed by partial nephrectomy. Functional data at 4 time points included preoperative serum creatinine, peak postoperative serum creatinine, new baseline serum creatinine 3 to 12 months postoperatively and long-term followup serum creatinine more than 12 months postoperatively. Adjusted acute kidney injury was defined by the ratio, observed peak postoperative serum creatinine/projected postoperative serum creatinine adjusted for parenchymal mass loss to reveal the true effect of ischemia. The long-term change in renal function (the long-term functional change ratio) was defined as the most recent glomerular filtration rate/the new baseline glomerular filtration rate. The relationship between the grade of the adjusted acute kidney injury and the long-term functional change was assessed by Spearman correlation analysis and multivariable regression., Results: Median patient age was 64 years and median followup was 45 months. Median parenchymal mass preservation was 80%. Adjusted acute kidney injury occurred in 42% of patients, including grade 1 injury in 20 (22%) and grade 2/3 in 18 (20%). On univariable analysis the degree of the adjusted acute kidney injury did not correlate with the long-term glomerular filtration rate change (p = 0.55). On multivariable analysis adjusted acute kidney injury was not associated with a long-term functional change (p >0.05) while diabetes and warm ischemia were modestly associated with a long-term functional decline (each p <0.05)., Conclusions: Acute kidney injury after partial nephrectomy was not a significant or independent predictor of long-term functional decline in our institutional cohort. A prospective study with larger sample sizes and longer followup is required to evaluate factors associated with long-term nephron stability., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Nephron mass preservation is a key determinant of functional outcomes after partial nephrectomy (PN), while ischemia plays a secondary role. Analyses focused specifically on recovery of the operated kidney appear to be most informative, yet have only included limited numbers of patients., Objective: To evaluate the relative impact of parenchymal preservation and ischemia on functional recovery after PN using a more robust cohort allowing for more refined perspectives about ischemia., Design, Setting, and Participants: A total of 401 patients managed with PN with necessary studies were analyzed for function and nephron mass preserved specifically within the kidney exposed to ischemia., Intervention: PN., Outcome Measurements and Statistical Analysis: The nephron mass preserved was measured from computed tomography scans <2 mo before and 3-12 mo after PN. Patients with two kidneys were required to have nuclear renal scans within the same timeframes. Recovery from ischemia was defined as the percent function preserved normalized by the percent nephron mass preserved. Pearson correlation was used to evaluate relationships between functional recovery and nephron mass preservation or ischemia time. Multivariable linear regression assessed predictors for recovery from ischemia., Results and Limitations: The median tumor size was 3.5cm and the median RENAL score was 8. Cold and warm ischemia were utilized in 151 and 250 patients, and the median ischemia time was 27 and 21min, respectively. The function preserved was strongly correlated with nephron mass preserved(r=0.63; p<0.001). Median recovery from ischemia was significantly higher for hypothermia (99% vs 92%; p<0.001) and remained consistently strong even with longer duration. Multivariable analysis demonstrated that recovery from ischemia, which normalizes for nephron mass preservation, was significantly associated with ischemia type and duration (both p<0.05). However, each additional 10min of warm ischemia was associated with only a 2.5% decline in recovery from ischemia. Limitations include the retrospective design., Conclusions: Our data suggest that functional recovery from clamped PN is most reliable with hypothermia. Longer intervals of warm ischemia are associates with reduced recovery; however, incremental changes are modest and may not be clinically significant in patients with a normal contralateral kidney., Patient Summary: Functional recovery after clamped partial nephrectomy is primarily dependent on preservation of nephron mass. Recovery is most reliable when hypothermia is applied. Longer intervals of warm ischemia are associated with reduced recovery; however, the incremental changes are modest., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: Parenchymal mass preservation, and ischemia type and/or duration can influence functional recovery after partial nephrectomy. Some groups have hypothesized that relevant comorbidities may also impact nephron stability and functional recovery but this has not been adequately investigated., Materials and Methods: At our center 405 patients treated with partial nephrectomy from 2007 to 2015 had the necessary data to determine the function and parenchymal mass preserved in the ipsilateral kidney. Comorbidities potentially associated with renal functional status were reviewed, including various degrees of hypertension, diabetes, cardiovascular disease, obesity, smoking status and related medications. Multivariable linear regression was done to assess factors associated with functional recovery, defined as the percent of preserved ipsilateral glomerular filtration rate., Results: Median tumor size was 3.5 cm and the median R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and tumor touching main renal artery or vein) score was 8. Warm and cold ischemia were done in 264 (65%) and 141 patients for a median duration of 21 and 27 minutes, respectively. The median preserved ipsilateral glomerular filtration rate was 79%. Patient age, comorbidity index, hypertension and proteinuria were each associated with the preoperative glomerular filtration rate (all p <0.01). On univariable and multivariable analyses the preserved parenchymal mass, and ischemia type and duration were significantly associated with functional recovery (all p <0.001). On univariable analysis of comorbidities only hypertension was significantly associated with functional recovery. However, on multivariable analysis none of the analyzed comorbidities were associated with functional recovery., Conclusions: Recovery of function after partial nephrectomy depends primarily on parenchymal mass preservation and ischemia characteristics. Comorbidities failed to be associated with functional outcomes. Comorbidities can impact function, leading to surgery, and may influence long-term functional stability. However, our data suggest that they do not influence short-term recovery after partial nephrectomy., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate contact surface area (CSA) between the tumor and parenchyma as a predictor of ipsilateral parenchyma and function preserved after partial nephrectomy (PN). Previous studies suggested that CSA is a strong predictor of functional outcomes but the limitations of CSA have not been adequately explored., Patients and Methods: Four hundred nineteen patients managed with standard PN for solitary tumor with necessary studies to evaluate and analyze ipsilateral preoperative or postoperative parenchymal mass and function. Parenchymal mass and CSA were measured using contrast-enhanced computed tomography <2 months prior and 3-12months after PN. CSA was calculated: 2πrd, where r = radius and d = intraparenchymal depth. Pearson-correlation evaluated relationships between CSA and ipsilateral parenchymal mass or function preserved. Multivariable regression assessed predictors of function preserved. Conceptually, the CSA paradigm should function better for exophytic tumors than endophytic ones., Results: Median tumor size was 3.5 cm and R.E.N.A.L. was 8. Median global and ipsilateral glomerular filtration rate preserved were 89% and 79%, respectively. Median ipsilateral parenchymal mass preserved was 85% and significantly higher for exophytic masses (P = .001). Median CSA was 22.8 cm 2 and significantly less for exophytic masses (P = .02). CSA associated with both ipsilateral function and mass preserved (both P < .05), but the correlations were only modest (r = 0.25 and 0.36, respectively). On multivariable analysis, CSA associated with function preserved for exophytic masses (P = .01), but not for endophytic ones (P = .27)., Conclusion: CSA associates with functional outcomes after standard PN, although the strength of the correlations was modest, unlike previous studies, and CSA was not an independent predictor for endophytic tumors. Further study will be required to evaluate the utility of CSA in various clinical settings., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Renal cancer surgery can adversely impact long-term function and survival. We evaluated predictors of chronic kidney disease 5 years and nonrenal cancer mortality 10 years after renal cancer surgery., Materials and Methods: We analyzed the records of 4,283 patients who underwent renal cancer surgery from 1997 to 2008. Radical and partial nephrectomy were performed in 46% and 54% of patients, respectively. Cumulative probability ordinal modeling was used to predict chronic kidney disease status 5 years after surgery and multivariable logistic regression was used to predict nonrenal cancer mortality at 10 years. Relevant patient, tumor and functional covariates were incorporated, including the preoperative glomerular filtration rate (A), the new baseline glomerular filtration rate after surgery (B) and the glomerular filtration rate loss related to surgery (C), that is C = A - B. In contrast, partial or radical nephrectomy was not used in the models due to concerns about strong selection bias associated with the choice of procedure., Results: Multivariable modeling established the preoperative glomerular filtration rate and the glomerular filtration rate loss related to surgery as the most important predictors of the development of chronic kidney disease (Spearman ρ = 0.78). Age, gender and race had secondary roles. Significant predictors of 10-year nonrenal cancer mortality were the preoperative glomerular filtration rate, the new baseline glomerular filtration rate, age, diabetes and heart disease (all p <0.05). Multivariable modeling established age and the preoperative glomerular filtration rate as the most important predictors of 10-year nonrenal cancer mortality (c-index 0.71) while the glomerular filtration rate loss related to surgery only changed absolute mortality estimates 1% to 3%., Conclusions: Glomerular filtration rate loss related to renal cancer surgery, whether due to partial or radical nephrectomy, influences the risk of chronic kidney disease but it may have less impact on survival. In contrast, age and the preoperative glomerular filtration rate, which reflects general health status, are more robust predictors of nonrenal cancer mortality, at least in patients with good preoperative function or mild chronic kidney disease., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: Robot-assisted partial nephrectomy (RAPN) with different arterial clamping techniques has increasingly been performed to avoid ischemic injury to nephron. However, postoperative renal function remains controversial. We determine the impact of each renal arterial clamping on surgical and renal outcomes after RAPN., Materials and Methods: Patients who underwent RAPN at Siriraj Hospital from 2010 to 2016 were retrospectively reviewed and stratified into 3 cohorts: main-clamp (MAC), selective-clamp, and off-clamp., Results: Main, selective, and off-clamping were performed in 27, 38, and 12, respectively. Median tumor size and Radius, Exophytic or endophytic, Nearness to collecting system or sinus, Anterior or posterior, and Location relative to polar lines (RENAL) score were 3 cm and 7, respectively. Longer operative time was observed in MAC (p = 0.002) although estimated blood loss, transfusion rate, and complication were comparable. Warm ischemia time was not different between cohorts. However, number of patients with prolonged ischemia time in MAC were greater (p ≤ 0.01). All margins were negative. Median postoperative and latest glomerular filtration rate reduction were 3.8 and 5.3 mL/min/1.73 m2, respectively without significant difference between cohorts. On multivariable analysis, hypertension independently associated with reduced renal function preserved (p = 0.03). Median follow-up was 18 months., Conclusions: Our study is the first to report surgical and renal functional outcomes after RAPN in Southeast-Asian population. Based on our experience, clamping techniques does not impact on renal functions and complication rate was low even in small-volume center., (© 2018 S. Karger AG, Basel.)

Objectives: To evaluate predictors of long-term survival for patients with chronic kidney disease primarily due to surgery (CKD-S). Patients with CKD-S have generally good survival that approximates patients who do not have CKD even after renal cancer surgery (RCS), yet there may be heterogeneity within this cohort., Patients and Methods: From 1997 to 2008, 4 246 patients underwent RCS at our centre. The median (interquartile range [IQR]) follow-up was 9.4 (7.3-11.0) years. New baseline glomerular filtration rate (GFR) was defined as highest GFR between nadir and 6 weeks after RCS. We retrospectively evaluated three cohorts: no-CKD (new baseline GFR of ≥60 mL/min/1.73 m 2 ); CKD-S (new baseline GFR of <60 mL/min/1.73 m 2 but preoperative GFR of ≥60 mL/min/1.73 m 2 ); and CKD due to medical aetiologies who then require RCS (CKD-M/S, preoperative and new baseline GFR both <60 mL/min/1.73 m 2 ). Analysis focused primarily on non-renal cancer-related survival (NRCRS) for the CKD-S cohort. Kaplan-Meier analysis assessed the longitudinal impact of new baseline GFR (45-60 mL/min/1.73 m 2 vs <45 mL/min/1.73 m 2 ) and Cox regression evaluated relative impact of preoperative GFR, new baseline GFR, and relevant demographics/comorbidities., Results: Of the 4 246 patients who underwent RCS, 931 had CKD-S and 1 113 had CKD-M/S, whilst 2 202 had no-CKD even after RCS. Partial/radical nephrectomy (PN/RN) was performed in 54%/46% of the patients, respectively. For CKD-S, 641 patients had a new baseline GFR of 45-60 mL/min/1.73 m 2 and 290 had a new baseline GFR of <45 mL/min/1.73 m 2 . Kaplan-Meier analysis showed significantly reduced NRCRS for patients with CKD-S with a GFR of <45 mL/min/1.73 m 2 compared to those with no-CKD or CKD-S with a GFR of 45-60 mL/min/1.73 m 2 (both P ≤ 0.004), and competing risk analysis confirmed this (P < 0.001). Age, gender, heart disease, and new baseline GFR were all associated independently with NRCRS for patients with CKD-S (all P ≤ 0.02)., Conclusion: Our data suggest that CKD-S is heterogeneous, and patients with a reduced new baseline GFR have compromised survival, particularly if <45 mL/min/1.73 m 2 . Our findings may have implications regarding choice of PN/RN in patients at risk of developing CKD-S., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

Purpose: Parenchymal mass loss is the predominant factor associated with functional outcomes after partial nephrectomy. It is primarily due to excised and/or devascularized parenchymal mass. We evaluated the importance of excised and devascularized parenchymal mass relative to functional recovery after partial nephrectomy., Materials and Methods: In 168 patients who underwent partial nephrectomy the necessary studies were done to determine excised and devascularized parenchymal mass, and evaluate parenchymal mass changes and functional loss of the operated kidney. Parenchymal mass loss in the ipsilateral kidney was measured on contrast enhanced computerized tomography less than 2 months before and 3 to 12 months after partial nephrectomy. Excised parenchymal mass was estimated by subtracting tumor volume from specimen volume. Devascularized parenchymal mass was defined as total parenchymal mass loss minus excised parenchymal mass. We used the Pearson correlation to evaluate relationships between glomerular filtration rate preservation and parenchymal mass loss. Multivariable analysis was done to assess factors associated with devascularized parenchymal mass., Results: Median tumor size was 3.4 cm and median R.E.N.A.L. (radius, exophytic/endophytic tumor properties, nearness of tumor to collecting system or sinus, anterior/posterior and location relative to polar lines) score was 7. Warm and cold ischemia was used in 100 and 68 patients, respectively. Median excised parenchymal and devascularized parenchymal mass was 9 and 16 cm 3 , respectively (p <0.001). Total parenchymal mass loss and devascularized parenchymal mass were associated strongly with glomerular filtration rate preservation in the operated kidney (each r ≥0.55, p <0.001). However, excised parenchymal mass was only weakly associated with functional outcomes (r = 0.23). The preoperative glomerular filtration rate and endophytic status were associated with devascularized parenchymal mass on multivariable analysis., Conclusions: To our knowledge we report the first study to specifically evaluate the relative contributions of devascularized and excised parenchymal mass to functional recovery after partial nephrectomy. Our study suggests that devascularized parenchymal mass has more impact, which may have implications regarding surgical technique. Prospective study is required to further evaluate the relative contributions of excised and devascularized parenchymal mass in various settings., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Tumor enucleation (TE) optimizes parenchymal preservation and could yield better function than standard partial nephrectomy (SPN), although data on this are conflicting., Objective: To compare functional outcomes for TE and SPN strategies., Design, Setting, and Participants: Patients managed with partial nephrectomy (PN) with necessary data for analysis of preservation of ipsilateral parenchymal mass (IPM) and global glomerular filtration rate (GFR) from two centers were included. All studies were required <2 mo before and 3-12 mo after surgery. Patients with a solitary kidney or multifocal tumors were excluded., Intervention: Partial nephrectomy., Outcome Measurements and Statistical Analysis: Vascularized IPM was estimated from contrast-enhanced CT scans preoperatively and postoperatively. Serum creatinine-based estimates of global GFR were also obtained in the same timeframes. Univariable and multivariable linear regression evaluated factors associated with new-baseline global GFR., Results/limitations: Analysis included 71 TE and 373 SPN cases. The median preoperative global GFR was comparable for TE and SPN (75 vs 78ml/min/1.73m 2 ; p=0.6). The median tumor size was 3.0cm for TE and 3.3cm for SPN (p=0.03). The median RENAL score was 7 in both cohorts. For TE, warm ischemia and zero ischemia were used in 51% and 49% of cases, respectively. For SPN, warm ischemia and cold ischemia were used in 72% and 28% of patients, respectively. Capsular closure was performed in 46% of TE and 100% of SPN cases (p<0.001). Positive margins were found in 8.5% of TE and 4.8% of SPN patients (p=0.2). The median vascularized IPM preserved was 95% (interquartile range [IQR] 91-100%) for TE and 84% (IQR 76-92%) for SPN (p<0.001). The median global GFR preserved was 101%(IQR 93-111%) and 89% (IQR 81-96%) for TE and SPN, respectively (p<0.001). On multivariable analysis, resection strategy, preoperative GFR, and vascularized IPM preserved were all significantly associated (p<0.001) with new-baseline global GFR. Limitations include the retrospective design and the lack of resection outcome data., Conclusions: Our analysis suggests that TE has potential for maximum IPM preservation compared to SPN and may provide optimized functional recovery. Further investigation will be required to evaluate the clinical significance of these findings., Patient Summary: Tumor enucleation for kidney cancer involves dissection along the tumor capsule and optimally preserves normal kidney tissue, which may lead to better functional recovery. The importance of this approach in various clinical settings will require further investigation., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate whether excised parenchymal mass (EPM) during partial nephrectomy (PN) correlates with functional decline and can serve as a surrogate for functional outcomes., Materials and Methods: All 215 patients managed with PN for unifocal renal mass with necessary studies to determine EPM and percent glomerular filtration rate (GFR) and parenchymal mass preserved (both global and specific to the operated kidney) were analyzed. EPM was estimated from the pathologic specimen by subtracting the tumor mass from the specimen mass, with both calculated using the elliptical formula. Vascularized parenchymal mass preserved was measured from computed tomography scans obtained <2 months prior and 3-12 months after surgery. All functional analyses were required to be within the same time frames, and patients with a contralateral kidney were also required to have nuclear renal scans., Results: The median tumor size was 3.5 cm and the median R.E.N.A.L. was 7. Warm and cold ischemia were utilized in 123 and 92 patients, respectively (median ischemia time = 23 minutes). The median global GFR preserved was 89%, the median total parenchymal mass preserved was 93%, and the median estimated EPM was 16 cm 3 . Whereas percent parenchymal mass preserved correlated strongly with global and ipsilateral GFR preserved (both P < .001), EPM failed to correlate with functional outcomes on both univariable and multivariable analyses., Conclusion: Our data suggest that parenchymal mass preserved with standard PN by experienced surgeons associates strongly with function preserved, whereas EPM fails to correlate with functional outcomes. Further study of the functional impact of EPM in other circumstances will be required, such as enucleation or PN performed by less-experienced surgeons., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Renal function after renal cancer surgery is a critical component of survivorship. Quantity and quality of preserved parenchyma are the most important determinants of functional recovery; type and duration of ischemia play secondary roles. Several studies evaluated surgical techniques to minimize ischemia; however, long-term outcomes and potential benefits over clamped partial nephrectomy (PN) have not been consistently demonstrated. Analysis of acute kidney injury (AKI) after PN suggest that most kidneys recover strongly even if AKI is experienced after surgery. Ongoing study is required to evaluate long-term implications of AKI after PN and further assess impact of ischemia on functional outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

We report the case of a 51-year-old Thai female presented with right abdominal mass with pain and anemia. The radiographic findings showed ruptured renal mass. She underwent radical nephrectomy and the pathological report was malignant neuroendocrine tumor. Palliative chemotherapy was administered. The patient passed away three months after the operation. Renal neuroendocrine tumors are rare. Moreover, ruptured renal tumors are very rare. They are usually considered to be angiomyolipoma or renal cell carcinoma. Poor differentiation and rupture at presentation are aggressive features of tumors. To the best of our knowledge, this is the first case report of ruptured renal malignant neuroendocrine tumor.