Management Of Renal Masses Research Articles

Diagnostic accuracy and clinical impact of renal biopsy cytology.

The role of fine needle biopsy cytology in the workup of renal mass lesions remains controversial. With advances in imaging technology and clinical management for renal masses, a critical reevaluation of the role of renal biopsy is needed. This study was designed to provide a comprehensive evaluation of the performance and clinical impact of fine needle biopsy in patients with renal masses. A 5-year retrospective study of ultrasound or computer tomography (CT)-guided fine needle biopsies of renal masses diagnosed via cytopathology was conducted. Overall diagnostic rate, sensitivity, and diagnostic accuracy were calculated. Further analysis of the impact of fine needle biopsy cytology on clinical management was performed. A total of 227 cases of fine-needle aspiration and/or biopsy (FNA/B) of renal masses were identified, including 76 with subsequent nephrectomies. Complications were rare (<1%). The diagnostic rate and sensitivity of FNA/B were 83.3% and 89.5%, respectively. Diagnostic accuracy was 98.7% at the major categorical level and 94.7% at the tumor subtype level. Subsequent clinical actions were associated with a definitive cytologic diagnosis of malignancy/neoplasia (p < .05) and were affected by tumor subtype (p < .05). This study demonstrates that FNA/B of renal masses is a safe and reliable minimally invasive diagnostic tool with excellent accuracy in confirmation of malignancy and subclassification of tumors. Diagnoses made on FNA/B play a key role in guiding a personalized clinical treatment plan.

Outcomes of open versus robotic partial nephrectomy: a 20-year single institution experience.

Robotic assisted partial nephrectomy (RPN) has emerged in urologic practice for the management of appropriately sized renal masses. We provide a 20-year comparison of the outcomes of open partial nephrectomy (OPN) versus RPN for renal cell carcinoma (RCC) at our institution. An IRB-approved retrospective review was conducted of RCC patients at a single institution from 2000 to 2022 who underwent RPN or OPN. In addition to demographics, procedural details including ischemia and operative time were collected. Oncologic outcomes were evaluated through Kaplan-Meier statistical analysis to determine recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) analysis. 849 patients underwent RPN while 385 underwent OPN. 61% were male with average age of 58.8 ± 12.8years. Operative time was shorter in the open group (184 vs 200min, p = 0.002), as was ischemia time (16 vs 19min, p = 0.047). However, after 2012, RPN became more common than OPN with improving ischemia time. RPN patients had significantly improved RFS (HR 0.45, p = 0.0004) and OS (HR 0.51, p = 0.0016) when controlled for T-stage and margin status. More > pT1 masses were managed with OPN than RPN (11.2 vs 5.4%, p < 0.0001). At our institution, RPN had an increasing incidence with reduced ischemia time compared to OPN over the last 10years. While higher stage renal masses were more often managed with OPN, selective use of RPN does offer improved oncologic outcomes. Further investigation is needed to evaluate optimization of the selection of RPN versus OPN in the nephron-sparing management of renal masses.

Bilateral simultaneous partial nephrectomy

Introduction. Partial nephrectomy is the treatment of choice for small renal tumors. There are other indications include tumors in a solitary kidney, multiple and bilateral tumors.Сase presentation. A 67-year-old male presented with left flank pain and lower urinary tract symptoms. Computed tomography for abdominal and pelvis showed bilateral renal masses. After doing the essential laboratory tests and investigations, he underwent bilateral open simultaneous partial nephrectomies. After two days, he was discharged with no complains. Follow-up after three months showed no recurrence and acceptable renal function.Discussion. Partial nephrectomy is increasingly used for the management of renal masses. The preservation of renal function with reduced morbidity and equivalent oncologic outcomes led to a paradigm shift away from radical nephrectomy.Conclusion. Bilateral partial nephrectomy is feasible with both clinical and oncological good results.

The impact of sestamibi scan on clinical decision-making for renal masses: An observational single-center study.

We aimed to determine whether sestamibi scan changes management of renal masses. All patients undergoing sestamibi scan for renal masses between 2008 and 2022 at a single center were retrospectively reviewed. Data were gathered on patient demographics, pre- and postoperative creatinine, sestamibi scan parameters, and cross-sectional imaging characteristics. Outcomes included whether the patient underwent renal mass biopsy or surgical resection and the final pathological diagnosis if tissue was obtained from biopsy or resection. Data regarding postbiopsy as well as postoperative complications were also collected. The odds ratio (OR) for surgery or biopsy based on sestamibi result was calculated. Forty-three patients underwent sestamibi scan from 2008 to 2022, with 10 scans consistent with oncocytoma and 33 with nononcocytoma. The mean tumor size at initial presentation was 4.0 ± 1.8 cm with a median RENAL score of 7 (range: 4-11). For patients with sestamibi scans negative for oncocytoma, the OR for surgery was 12.5 (95% confidence interval [CI]: 2.1-71.2, P = 0.005), and the OR for biopsy was 0.04 (95% CI: 0.005-0.39, P = 0.005). Conversely, for patients with sestamibi scans positive for oncocytoma, the OR for surgery was 0.28 (95% CI: 0.03-2.4, P = 0.24) and the OR for biopsy was 24.0 (95% CI: 2.6-222.7, P = 0.005). Creatinine at the last follow-up was similar between patients with positive and negative sestamibi scans. No patients experienced complications from surgery or biopsy. The median follow-up was 19 months (range: 2-163). A sestamibi scan positive for oncocytoma led to increased use of renal mass biopsy for confirmation. Sestamibi scans that were negative for oncocytoma were more likely to result in surgical resection without biopsy.

Clear cell likelihood score may improve diagnosis and management of renal masses.

The detection of solid renal masses has increased over time due to incidental findings during imaging studies conducted for unrelated medical conditions. Approximately 20% of lesions measuring less than 4cm are benign and 80% are malignant. Clear cell renal cell carcinoma (ccRCC) is the most frequent among renal carcinomas, responsible for 65-80% of cases. The increased detection of renal masses facilitates early diagnosis and treatment. However, it also leads to more invasive interventions, which result in higher morbidity and costs. Currently, only histological analysis can offer an accurate diagnosis. Surgical nephron loss significantly elevates morbidity and mortality rates. Active surveillance represents a conservative management approach for patients diagnosed with a solid renal mass that is endorsed by both American Urological Association and the European Society for Medical Oncology. However, active surveillance is used in a minority of patients and varies across institutions. The lack of clinical studies using a standardized approach to incidentally detected small renal masses precludes the widespread use of active surveillance. Hence, there is an urgent need for better patient selection, distinguishing those who require surgery from those suitable for active surveillance. The clear cell likelihood score (ccLS) represents a novel MRI tool for assessing the probability of a renal mass being a ccRCC. In this study, we present a comprehensive review of renal masses and their evaluation using the ccLS to facilitate shared decision between urologists and patients.

Clinical safety and efficacy of microwave ablation for small renal masses.

CT-guided MWA is a safe and effective tool that should be utilized in the treatment of small renal masses (SRMs). We aim to clarify the utility of CT-guided MWA by examining patient outcomes such as recurrence, treatment success, changes in renal function, and complications. A retrospective review of consecutive patients with SRMs who underwent same day renal mass biopsy (RMB) and CT-guided MWA between 2015 and 2022 was performed. Treatment safety was assessed by 30-day complications according to the Clavien-Dindo system and change in eGFR >30 days post-procedure. Treatment efficacy was defined by local recurrence and incomplete treatment rates and calculated using the Kaplan-Meier method. A total of 108 renal masses were found in 104 patients. The overall complication rate was 7.4% (8/108), of which 4 were major complications (3.7%). For those with renal function available >30 days post ablation, the median eGFR was 47.2 (IQR: 36.0, 57), compared to 52.3 (IQR: 43.7, 61.5) pre-ablation, p<0.0001. 5-year local recurrence free survival was 86%. Among those with biopsy proven malignancy (n= 66), there were five local recurrences (7.54%) occurring at a median of 25.1 months (IQR 19.9, 36.2) and one case (1.5%) of incomplete treatment. As the medical field continues to evolve towards less invasive interventions, MWA offers a valuable tool in the management of renal masses. With low major complication and recurrence rates, our findings support the utility of CT-guided MWA as a tool for treatment of SRMs.

Perioperative and functional outcomes following robot-assisted partial nephrectomy: Descriptive analysis of Indian study group on partial nephrectomy database.

There is an unmet need for high-quality data for Robot-assisted partial nephrectomy (RAPN) in the Indian population. Indian study group on partial nephrectomy (ISGPN) is a consortium of Indian centers contributing to the partial nephrectomy (PN) database. The current study is a descriptive analysis of perioperative and functional outcomes following RAPN. For this study, the retrospective ISGPN database was reviewed, which included patients who underwent RAPN for renal masses at 14 centers across India from September 2010 to September 2022. Demographic, clinical, radiological, perioperative, and functional data were collected and analyzed. Ethics approval was obtained from each of the participating centers. In this study, 782 patients were included, and 69.7% were male. The median age was 53 years (interquartile range [IQR 44-62]), median operative time was 180 min (IQR 133-240), median estimated blood loss was 100 mL (IQR 50-200), mean warm ischemia time was 22.7 min and positive surgical margin rates were 2.5%. The complication rate was 16.2%, and most of them were of minor grade. Trifecta and pentafecta outcomes were attained in 61.4% and 60% of patients, respectively. This is the largest Indian multi-centric study using the Indian Robotic PN Collaborative database to evaluate the outcomes of robot-assisted PN, and has proven its safety and efficacy in the management of renal masses.

PE062 - Long-term high-volume experience of robotic retroperitoneal and transperitoneal partial nephrectomy in the management of renal masses – what should be the default approach?

PE062 - Long-term high-volume experience of robotic retroperitoneal and transperitoneal partial nephrectomy in the management of renal masses – what should be the default approach?

Open versus robot-assisted partial nephrectomy for highly complex renal masses: a meta-analysis of perioperitive and functional outcomes.

Robot-assisted partial nephrectomy (RAPN) is increasingly being used for the complex surgical management of renal masses. The comparison of RAPN with open partial nephrectomy (OPN) has not yet led to a unified conclusion with regard to perioperative outcomes. To conduct a systematic review and meta-analysis of the literature on the perioperative outcomes of RAPN compared with OPN. We performed a systematic search in PubMed, Embase, Web of Science, and Cochrane Library database for randomized control trials (RCTs) and non-RCTs that compare OPN to RAPN. The primary outcomes included perioperative, functional and oncologic. The odds ratio (OR) and weighted mean difference (WMD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CIs). Five studies, comprising 936 patients, were included in the meta-analysis. Our findings indicated that there were no significant differences in blood loss, minor complication rate, eGFR decline from baseline, positive surgical margin, and ischemia time between OPN and RAPN. However, RAPN was associated with a shorter hospital stay (WMD 1.64days, 95% CI -1.17 to 2.11; p < 0.00001), lower overall complication rate (OR 1.72, 95% CI 1.21-2.45; p < 0.002), lower transfusion rate (OR 2.64, 95% CI 1.39-5.02; p = 0.003) and lower major complication rate (OR 1.76, 95% CI 1.11-2.79; p < 0.02) compared to OPN. Additionally, the operation time for OPN was shorter than that for RAPN (WMD -10.77min, 95% CI -18.49 to -3.05, p = 0.006). In comparison with OPN, RAPN exhibits better results in terms of hospital stay, overall complications, blood transfusion rate, and major complications, with no significant difference in intraoperative blood loss, minor complications, PSM, ischemia time, and short-term postoperative eGFR decline. However, the operation time of OPN is slightly shorter than that of RAPN.

Factors predicting the active treatment of renal angiomyolipoma: 30 years of experience in two tertiary referral centers.

This study aimed to identify clinical features representing predictive factors of active treatment (AT) compared to active surveillance (AS) for renal angiomyolipoma (AML). From 1990 to 2020, patients referred to two institutions for a renal mass and diagnosed with an AML based on typical features on CT were included in the analysis. The study population was divided into two groups based on the treatment received: active surveillance (AS) or active treatment (AT). Age, gender, tuberous sclerosis syndrome, tumor size, contralateral kidney disease, renal function, year of diagnosis, and symptoms at presentation were assessed as potential predictive factors of active treatment using a logistic regression model in univariate and multivariate analyses. In total, 253 patients (mean age 52.3 ± 15.7 years; 70% women; 70.9% incidentally diagnosed) were included in the analysis. One hundred and nine (43%) received AS, whereas 144 (57%) were actively treated. For univariate analysis, age, tuberous sclerosis complex syndrome, tumor size, symptoms at presentation, and contralateral kidney disease were found to be predictors of AT. Only tumor size (p < 0.001) and the year of diagnosis (p < 0.001) remained significant for multivariable analyses. The likelihood of being managed with AS evolved over the study period and was 50% and 75% when diagnosed before and after 2010, respectively. With respect to size, 4-cm and 6-cm tumors had a probability of 50% and 75% of being treated with AS, respectively. The present analysis from a high-volume institution provides evidence that the management of renal masses with typical radiological features of AML has markedly changed over the last three decades with a trend toward AS over AT. Tumor size and the year of diagnosis were significant factors for the treatment strategies.

Long term experience of robotic retroperitoneal partial nephrectomy as the default approach in the management of renal masses: should the paradigm shift?

Although retroperitoneal surgery has demonstrated a better quality of recovery compared to transperitoneal routes, Retroperitoneal Robot Assisted Partial Nephrectomy (RRAPN) remains proportionally infrequent. As the boundaries of what is achievable robotically continue to be pushed, we present our experience at a high-volume tertiary referral centre that specialises in retroperitoneal surgery, exploring its feasibility as standard of care in the management of small renal masses. A prospective database of 784 RAPNs (2009-2020) was reviewed and 721 RRAPNs (92%) were performed at our centre. In our practice, we utilise a four-port approach to RRAPN. Patient, tumour and operative characteristics were assessed and both oncological outcomes and trifecta and pentafecta achievements were determined. Pentafecta was defined as achieving trifecta (negative surgical margin, no post-operative complications and WIT of < 25min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1year. Multivariate analysis was conducted to predict peri-operative factors which may prevent achieving a trifecta/pentafecta outcome. From 784 cases, 112 RAPNs were performed for imperative reasons, whilst the remainder were elective. Mean BMI ± s.d amongst our cohort was 28.6 ± 5.7. Mean tumour size was 3.1cm (range 0.8-10.5cm) and 47% of cases were stratified as intermediate/high risk using R.E.N.A.L nephrometry scoring. Forty-six patients had lesions in a hilar location, and 31% were anterior. Median blood loss was 30mls, with an open conversion rate of 1% and transfusion rate of 1.6%. Median warm ischaemic time (WIT) was 21min, positive surgical margins were found in 4% and our post-operative Clavien 3/ > complication rate was 2.6%. We had a 1-day median length of stay with a 30day readmission rate of 2%. Of 631 patients (80%) with a definitive histological diagnosis of cancer, 23% had T1b/ > disease. Over a mean 15month follow-up period (range 1-125months), 2% of patients developed recurrences and our cohort demonstrated a 99% 5year cancer specific survival. Trifecta was achieved in 67% of cases and pentafecta in 47%. Age (p = 0.05), operative time (p = 0.008), pT1b tumours (p = 0.03), R.E.N.A.L score and blood loss (p = 0.001) were found to statistically significantly influence achievement of trifecta. Pentafecta achievement was influenced by R.E.N.A.L score (p = 0.008), operative time (p = 0.001) and blood loss (p = 0.001). We demonstrate the retroperitoneal approach in RAPN is feasible and safe irrespective of lesion location and complexity. In the hands of high-volume centres that are skilled in the retroperitoneal approach the benefits of retroperitoneal surgery can be extended even to challenging cohorts of patients without compromising their oncological or functional outcomes.

Reliability and Management Outcomes Following a Percutaneous Biopsy Diagnosis of Oncocytoma: A 15-year Retrospective Analysis.

Background There is uncertainty in the management of renal masses diagnosed as oncocytomas with image-guided percutaneous biopsy. Purpose To assess the reliability of a diagnosis of oncocytoma based on image-guided percutaneous renal mass biopsy and evaluate patient outcomes following different management strategies. Materials and Methods In this retrospective study, image-guided percutaneous biopsy pathology reports from April 2004 to April 2019 were searched for keywords "oncocytoma" and "oncocytic neoplasm" and compared with surgical pathology or repeat biopsy results. Patients with at least 12 months of clinical follow-up and known cause of death were grouped according to management strategies, and disease-specific survival and metastatic renal cell carcinoma (RCC)-free survival were compared. Mass growth rates were calculated with use of a normal linear mixed model. Results The database yielded 160 biopsy reports of 149 renal masses in 139 patients; 149 masses were categorized as oncocytoma (n = 107), likely oncocytoma (n = 12), oncocytic neoplasm (n = 28), and indeterminate with oncocytoma in differential (n = 2). Biopsied masses categorized as oncocytoma or likely oncocytoma were oncocytomas in 16 of 17 masses (94%) based on surgical pathology or repeat biopsy; four of eight masses (50%) categorized as oncocytic neoplasms were low-grade RCCs. Outcome analysis included 121 patients (mean age ± SD, 68 years ± 9.1; 82 men); 80 patients initially underwent active surveillance (11 were later treated), 33 underwent ablation, and eight underwent surgery. Disease-specific survival and metastatic-free survival were 100% after each management strategy (median follow-up, 86.6 months; range, 14.2-207.9 months). Mass growth rate (mean, 1.7 mm per year) showed no evidence of a significant difference among biopsy result categories (P = .37) or initial (P = .84) or final management strategies (P = .11). Conclusion Image-guided percutaneous biopsy diagnosis of renal oncocytoma was reliable. Although some masses diagnosed as oncocytic neoplasms were low-grade renal cell carcinomas (RCCs) at final diagnosis, no patients died of RCC, including those managed with active surveillance. © RSNA, 2023 See also the editorial by Lockhart in this issue.

Comprehensive Management of Renal Masses in Solitary Kidneys

BackgroundA renal mass in a solitary kidney (RMSK) has traditionally been managed with partial nephrectomy (PN), although radical nephrectomy (RN) is occasionally required. Most RMSK studies have focused on patients for whom PN was achieved. ObjectiveTo provide a comprehensive analysis of the management strategies/outcomes for an RMSK and address knowledge deficits regarding this challenging disorder. Design, setting, and participantsA total of 1024 patients diagnosed with an RMSK (1975–2022) were retrospectively evaluated. Baseline characteristics and pathologic/functional/survival outcomes were analyzed. InterventionPN/RN/cryoablation (CA)/active surveillance (AS). Outcome measurements and statistical analysisFunctional outcomes, perioperative morbidity/mortality, and 5-yr recurrence-free survival (RFS) were evaluated. Kruskal-Wallis and chi-square tests were used to compare cohorts, and log-rank test and Cox proportional hazard model were used for survival analysis. Results and limitationsOf 1024 patients, 842 underwent PN (82%), 102 CA (10%), 54 RN (5%), and 26 AS (3%). The median tumor size and RENAL([R]adius [tumor size as maximal diameter], [E]xophytic/endophytic properties of tumor, [N]earness of tumor deepest portion to collecting system or sinus, [A]nterior [a]/posterior [p] descriptor, and [L]ocation relative to polar lines) score were 3.7 cm and 8, respectively. The median follow-up was 53 mo. For PN, 95% were clamped, and the median warm and cold ischemia times were 22 and 45 min, respectively. For PN, the median preoperative glomerular filtration rate (GFR) was 57 ml/min/1.73 m2, and the median new baseline and 5-yr GFRs were 47 and 48 ml/min/1.73 m2, respectively. Dialysis-free survival for PN was 97% at 5 yr. Twenty-two (2.1%) patients with clear-cell renal cell carcinoma and RENAL score ≥10 (median = 11) received tyrosine kinase inhibitors (TKIs) to facilitate PN, leading to 57% median decrease of tumor volume; PN was accomplished in 20 (91%). Forty-one patients had planned RN (4.0%), most often due to severe pre-existing chronic kidney disease (CKD), and 13 were converted from PN to RN (1.5%). Clavien III–V perioperative complications were observed in 80 (8%) patients and 90-d mortality was 0.6%. Five-year RFS for PN, CA, and RN were 83%, 80%, and 72%, respectively (p = 0.03 for PN vs RN). ConclusionsNephron-sparing approaches are feasible and successful in most RMSK patients. PN for an RMSK is often challenging but can be facilitated by selective use of TKIs. RN is occasionally required due to severe CKD, over-riding oncologic concerns, or conversion from PN. This is the first large RMSK study to provide a comprehensive analysis of all management strategies/outcomes. Patient summaryKidney cancer in a solitary kidney is a major challenge for achieving cancer-free status and avoiding dialysis. Although partial nephrectomy is the principal treatment for a renal mass in a solitary kidney, other options are occasionally required to optimize outcomes.

The Impact of Venous Thromboembolism on Mortality and Morbidity During Nephrectomy for Renal Mass

To determine the morbidity, mortality, and costs associated with having concurrent venous thromboembolism (VTE) at the time of surgical resection of a renal mass. We identified 108,430 patients undergoing elective partial or radical nephrectomy for a renal mass from 2013 to 2017 using the Premier Healthcare database. The association of VTE with 90-day complication rates, mortality, ICU admission, readmission, and direct hospital costs (2019 US dollars) was determined with multivariable logistic regression and quantile regression models, respectively. Of the 108,430 patients who underwent elective partial or radical nephrectomy, 1.2% (n=1301) of patients were diagnosed with a preoperative VTE. Patients with preoperative VTE have higher rates of minor (odds ratio [OR] 1.47, 95% confidence inteval [CI] 1.34-1.62, P < .0001) and major complications (OR 2.53, 95% CI 2.23-2.86, P < .0001), mortality (OR 2.03, 95% CI 1.6-2.57, P < .0001), and readmissions (OR 1.73, 95% CI 1.57-1.90, P < .0001) compared to patients without preoperative VTE at the time of nephrectomy. Notably, the predicted probability for a major complication was significantly higher among patients with preoperative VTE who underwent either partial or radical nephrectomy, irrespective of the surgical approach utilized. Furthermore, rates of all types of complications except endocrine and soft tissue were significantly increased in patients undergoing nephrectomy with preoperative VTE compared to those without VTE. VTE at the time of nephrectomy is associated with significantly higher rates of major complications, increased mortality, and higher overall costs. Taken together, these findings have important implications for the counseling and management of renal masses in presence of VTE.

V10-12 COMPLEX PARTIAL NEPHRECTOMY IN SOLITARY KIDNEY

You have accessJournal of UrologyCME1 May 2022V10-12 COMPLEX PARTIAL NEPHRECTOMY IN SOLITARY KIDNEY Nimrod Barashi Gozal, Brijesh Patel, Mark Biebel, Joseph Ippolito, and Robert Figenshau Nimrod Barashi GozalNimrod Barashi Gozal More articles by this author , Brijesh PatelBrijesh Patel More articles by this author , Mark BiebelMark Biebel More articles by this author , Joseph IppolitoJoseph Ippolito More articles by this author , and Robert FigenshauRobert Figenshau More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002623.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Management of renal masses in solitary kidneys can pose a challenging dilemma. Important considerations include feasibility of mass resection with adequate renorrhaphy, limiting ischemia time, and preservation of nephrons to avoid dialysis. We present a complex robot-assisted partial nephrectomy (RAPN) in a 55 year-old female with a solitary left kidney, incidentally found to have a 5.7cm left renal mass that was centrally located, completely endophytic, with a R.E.N.A.L Nephrometry score of 11, and a baseline creatinine of 1.06 mg/dL. METHODS: The patient was placed in right lateral decubitus position with the left flank flexed. Pneumoperitoneum was achieved with a Veress needle, and four robotic 8 mm ports were placed in a straight line along the lateral edge of the rectus with a 12 mm assistant port in the midline. A remotely operated suction irrigation (ROSI) system was utilized. After the colon was medialized, hilar dissection was started with identifying the renal vein (RV), and immediately posterior and cephalad was the renal artery (RA). Intraoperative ultrasonography was performed to demarcate borders of mass excision, since the mass was completely endophytic. Approximately 50% of mass excision was performed with selective clamping of the artery supplying the tumor, but the main RA was eventually clamped to help control bleeding. The mass, along with a segment of tumor thrombus, was grossly excised to completion. Renorrhaphy was started with a 3-0 v-lock suture over-sewing the base of mass excision to control bleeding followed by simple interrupted 0-vicryl suture to bring edges of resection together. These were secured with two Hem-o-lok clips. Gerota’s fascia was re-approximated with a 3-0 v-lock suture, and the specimen was placed in a Endocatch bag for extraction through a Gibson incision. RESULTS: Procedure time was 5 hours and 13 minutes. Estimated blood loss (EBL) was 1,500 mL. Pathology showed clear cell RCC, Furhman grade 3, with lymphovascular invasion and a positive surgical margin at the RV. Post-operatively, the patient experienced a oliguric renal failure, with creatinine (Cr) peaking at 8.5 mg/dL on postoperative day 4. Following that, urine output increased to over 2 liters daily, and Cr fell to 5.5 mg/dL by POD#9, at which time the patient was discharged. At one month follow-up, Cr was 1.49 mg/dL. At no point did the patient have any dialysis needs. CONCLUSIONS: A number of difficult challenges exist for complex RAPN in solitary kidneys. Performing as much of the procedure as possible without clamping the main renal artery may increase blood loss but will also facilitate renal recovery. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e852 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nimrod Barashi Gozal More articles by this author Brijesh Patel More articles by this author Mark Biebel More articles by this author Joseph Ippolito More articles by this author Robert Figenshau More articles by this author Expand All Advertisement PDF DownloadLoading ...

PD56-06 SURGERY FOR RENAL MASSES IN HORSESHOE KIDNEYS

You have accessJournal of UrologyCME1 May 2022PD56-06 SURGERY FOR RENAL MASSES IN HORSESHOE KIDNEYS Yosuke Yasuda, J. J. Zhang, Nityam Rathi, Gustavo Roversi, Ao Zhang, Diego Palacios, Jihad Kaouk, Georges-Pascal Haber, Venkatesh Krishnamurthi, Robert Abouassaly, Christopher Weight, and Steven Campbell Yosuke YasudaYosuke Yasuda More articles by this author , J. J. ZhangJ. J. Zhang More articles by this author , Nityam RathiNityam Rathi More articles by this author , Gustavo RoversiGustavo Roversi More articles by this author , Ao ZhangAo Zhang More articles by this author , Diego PalaciosDiego Palacios More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Georges-Pascal HaberGeorges-Pascal Haber More articles by this author , Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author , Robert AbouassalyRobert Abouassaly More articles by this author , Christopher WeightChristopher Weight More articles by this author , and Steven CampbellSteven Campbell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002636.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgery for horseshoe kidneys with tumors presents challenges due to aberrant vascular anatomy and risk of AKI/CKD. We evaluate outcomes in this challenging patient population. METHODS: Patients who underwent management of a renal mass in a horseshoe kidney at our center (1999-2021) were reviewed. Baseline characteristics, surgical approach, complications, and pathologic, functional and survival outcomes were analyzed. RESULTS: 43 procedures were performed (42 patients) with horseshoe kidneys consisting of 24 (56%) partial nephrectomy (PN) and 19 (44%) radical nephrectomy (RN) with division of the isthmus. One patient had both RN and PN (Fig. 1). 26/43 cases (60%) were diagnosed incidentally (Table 1). Median tumor size and RENAL score were 4.3 cm and 8, respectively. On final pathology, only 27 (63%) tumors were RCC, and 10 (23%) were benign. Complex vascular anatomy was common (36% of patients). 25/43 (58%) of cases were performed open, the remainder were MIS. Of open cases, 68% were performed through a midline incision and 32% via alternate incisions. Median OR time was 233 min with median EBL 325cc; 12% were transfused. 90-day Clavien III-IV complication rate was 12%, and there were no mortalities. For PN, median warm ischemia time (IT) was 26 min and cold IT 31 min. New baseline/long-term eGFR were 67/66 ml/min/1.73m2 overall and 83/78 ml/min/1.73m2 after PN versus 48/57 ml/min/1.73m2 after RN (p=0.01/0.03). Dialysis was required in 7% overall (0% after PN). Tumor size, RENAL, and tumor stage were increased in the RN group. Median follow-up was 36 months. 5-yr RFS rates were 76 % overall and 83 % for PN versus 66 % for RN. Overall, 6 patients died of cancer. CONCLUSIONS: Management of renal masses in horseshoe kidneys is challenging and requires versatility with multiple surgical approaches to provide safe and effective outcomes. Preservation of renal function was accomplished in the majority of patients, with a functional advantage for PN. RCC was less common than usual, and benign tumors more prevalent, suggesting strong consideration for preoperative renal mass biopsy. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e955 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yosuke Yasuda More articles by this author J. J. Zhang More articles by this author Nityam Rathi More articles by this author Gustavo Roversi More articles by this author Ao Zhang More articles by this author Diego Palacios More articles by this author Jihad Kaouk More articles by this author Georges-Pascal Haber More articles by this author Venkatesh Krishnamurthi More articles by this author Robert Abouassaly More articles by this author Christopher Weight More articles by this author Steven Campbell More articles by this author Expand All Advertisement PDF DownloadLoading ...

Pathologic Findings and Management of Renal Mass in Horseshoe Kidneys

To evaluate the management, surgical outcomes, and pathological findings in patients with tumor in a horseshoe-kidney (HK). HK patients present unique challenges due to aberrant vascular anatomy and risk of renal insufficiency. We hypothesized that many tumors in this setting may be indolent or benign. Patients managed for renal mass in HK at our center (1999-2021) were reviewed. Baseline characteristics, surgical approach, complications, functional outcomes, pathology, and survival were analyzed. Forty-three procedures were performed in 42 patients with HK including 24 nephron-sparing surgeries (NSS) and 19 radical nephrectomies (RN: splitting the isthmus and saving the contralateral moiety). NSS included 22 partial nephrectomy (PN) and 2 thermal ablations. Median tumor size was 4.3 cm. Eighteen cases (42%) were minimally-invasive, 17 open-midline, and 8 other open approaches. Ninety-day Clavien III-V complication rate was 12% with no mortalities. For PN, median warm/cold ischemia times were 26/31 minutes, respectively. On pathology, only 27 tumors (63%) were renal-cell-carcinoma (RCC), and 22 tumors (51%) were either benign (n = 10) or low grade, confined RCC (n = 12). Preoperative/new baseline/long-term eGFR were 82/83/78 mL/min/1.73 m2 after NSS vs 75/48/57 mL/min/1.73 m2 after RN, respectively. Long-term dialysis was required in 3 patients (7%). Median follow-up was 36 months. Five-year recurrence-free survival was 83% for NSS and 66% for RN. Management of renal masses in HK is challenging and requires versatility with multiple surgical approaches. Preservation of renal function was accomplished in most patients, with a functional advantage observed for NSS. RCC was less common than expected while benign and non-aggressive tumors were prevalent, suggesting consideration for preoperative renal-mass-biopsy when feasible.

Robotic partial nephrectomy for management of renal mass in patients with a solitary kidney: can we expand the indication to T2 and T3 disease?

Management of complex renal masses is challenging in a solitary kidney setting. We retrospectively compared oncological and renal functional outcomes between robotic and open partial nephrectomy (PN) in patients with a pT2-pT3 renal mass and a solitary kidney. From a multi-institutional series, we identified 20 robotic partial nephrectomies (RPN) and 15 open partial nephrectomies (OPN) patients confirmed to have a pT2 or pT3 renal cancer. Surgeries were performed between January 2012 and July 2019. Patients with familial renal cell carcinoma, prior ipsilateral PN, or multiple ipsilateral synchronous tumors were excluded from the analysis. Baseline characteristics, perioperative and postoperative outcomes were compared using χ2 test, Fisher's Exact Test, Mann-Whitney U Test, and Student's t-test. Baseline characteristics were comparable. Cold ischemia was utilized more in the open group (92.9% vs. 15.8%, P<0.001). OPN group had a longer ischemia time (48.9 min vs. 27.3 min, P<0.001), a higher major complication rate (38.5% vs. 11.1%, P=0.009), and a higher length of stay was (5 vs. 3.5 days, P=0.023). Positive surgical margin rate was comparable (20% OPN vs. 15% RPN; P=1.000). At a mean follow up of 21 months local recurrence rates (1 OPN vs. 2 RPN, P=1.000) were comparable, chronic kidney disease upstaging rate (46.7% OPN vs. 45.0% RPN, P=0.922) and estimated glomerular filtration rate preservation at one year (75.2%% in OPN vs. 79.1% RPN, P=0.707) were comparable. In select cases and experienced hands, the robotic approach offers a reasonable alternative to open surgery in patients with pT2 and pT3 tumors and a solitary kidney.

A0219 - Assessing renal mass management of patients with increased comorbidities: Results from a statewide registry

A0219 - Assessing renal mass management of patients with increased comorbidities: Results from a statewide registry

Ultrasound-Guided Renal Mass Biopsy and Its Clinical Utility: A Single-Centre Experience

Introduction: Renal mass biopsy (RMB) is still underutilized, partially because many urologists argue that it does not substantially influence the management of renal masses. We sought to evaluate the influence of RMB on the management of renal tumours in our institution. Materials and Methods: A total of 387 RMBs performed at our institution from January 2016 to June 2020 were included. Patient demographics, mass size, biopsy result, and subsequent clinical management were retrospectively reviewed. Results: The mean mass size was 47.8 mm. Fifty-six percentage of tumours ≤40 mm (247) and 8% of tumours >40 mm (64) were biopsied. Seventy-six RMBs of disseminated tumours were performed. 14.9% of RMBs were non-diagnostic, and 27.1% of RMBs of tumours ≤40 mm were benign. The majority of tumours with first non-diagnostic RMB followed by histopathological verification were found to be malignant. There was significantly more conservative management and no radical nephrectomies in the benign biopsy group. One case of Clavien-Dindo grade ≥2 complication occurred. Conclusions: RMB result affects treatment decisions. Ultrasound-guided RMB is a safe procedure, and performing biopsies of tumours ≤40 mm may reduce the number of unnecessary interventions. Non-diagnostic RMBs should be repeated or treated as malignant.