Nephron-sparing Surgery Research Articles

Wilms’ Tumor – An Audit

ABSTRACT Background and Aims: Outcome analysis of patients with Wilms’ tumors (WT) is presented. Materials and Methods: A retrospective analysis of 23 children having WT managed by a single surgeon over 3 years (2021–2024) using the International Society of Paediatric Oncology Umbrella protocol was done. Results: The median age at presentation was 36 months; 32 months and 24 months for the unilateral WT (uWT) (n = 19) and bilateral WT (bWT) (n = 4), respectively. M: F ratio was 2.3: 1. WTs were localized in 19 (uWT-16; bWT-3) and metastatic in 4 (uWT-3; bWT-1) patients. Core-needle biopsy was done in 22 patients (26 renal units). Pre-therapy contrast-enhanced computed tomography volumetry (n = 20) showed a median tumor volume of 1023 ml (range: 47–2680 ml). Post-neoadjuvant chemotherapy (NACT) median tumor burden (n = 19) was 612 ml (range 59–3775 ml). Post-NACT, tumor volume decreased in 11/18 patients but increased in seven patients. NACT was avoided in one neonate. Nephroureterectomy (including one with excision of bladder cuff) and nephron-sparing surgery were done in 17 and 10 renal units including 3 with multifocal WT, respectively. Risk stratification was intermediate in 21 and High in 2. Overall staging in 19 uWT included Stage I-7, Stage II-5, Stage III-4, and Stage IV-3 (local staging-stage I in 1 and stage II in 2). Local staging in 8 renal units with bWT was Stage I in 7 and II in 1. One stage IV uWT had bilateral pulmonary metastatectomy. Adjuvant chemotherapy has been completed in 18 patients; two patients are still on adjuvant chemotherapy; flank radiation was administered in six patients. Three patients with synchronous bWT died; two due to acute kidney injury in the immediate postoperative period and one with metastatic disease who had abandoned adjuvant chemotherapy after the 1st cycle. Another patient died of a huge metachronous tumor in the contralateral kidney after a year of completion of therapy. One patient had successful multimodality treatment of local relapse with liver metastasis. 1-year overall and event-free survivals are 84% and 76%, respectively. Conclusions: Excellent short-term results for localized uWT from a center in a low-middle-income country are reported.

Multilocular Cystic Renal Neoplasia of Low-grade Malignant Potential: Evolving Diagnostic Criteria: A Case Report with Review of Literature

Multilocular Cystic Renal Neoplasm of Low Malignant Potential (MCRNLMP) is a distinct type of clear cell renal tumor. The diagnostic histological criteria for this entity have evolved, and specific histological features have been modified over the years. The WHO 2022 of Male Urinary System and Male Genital Tumours respecified diagnostic histopathological features. Maximum tumors are asymptomatic and are incidentally detected on radiological examination. Computed tomography using contrast agents is still the gold standard for classifying cystic tumors of kidney. The Bosniak category of renal cystic lesions is crucial for the management of other imaging modalities such as magnetic resonance imaging (MRI) and contrast-enhanced ultrasound, which can be used with the same effectiveness. The prognosis is excellent in MCRNLMP, and there are no reports of cancer progression or metastasis. Minimally invasive nephron-sparing surgery with strict clinical including imaging follow-up with contrast-enhanced computerized tomography and magnetic resonance imaging is a choice of treatment.

Impact of a kidney-adjusted ERAS® protocol on postoperative outcomes in patients undergoing partial nephrectomy

PurposeEvaluation of a kidney-adjusted enhanced recovery after surgery (ERAS®) protocol (kERAS) in patients undergoing nephron-sparing surgery (PN).MethodsThe kERAS protocol is a multidimensional protocol focusing on optimized perioperative fluid and nutrition management as well as strict intraoperative and postoperative blood pressure limits. It was applied in a prospective cohort (n = 147) of patients undergoing open or robotic PN. Patients were analyzed for the development of acute postoperative renal failure (AKI), achievement of TRIFECTA criteria, upstaging or new onset of chronic kidney disease (CKD) and length of hospital stay (LOS) and compared to a retrospective cohort (n = 162) without application of the protocol.ResultsCox regression analyses could not confirm a protective effect of kERAS on the development of AKI post-surgery. A positive effect was observed on TRIFECTA achievement (OR 2.2, 95% CI 1.0-4.5, p = 0.0374). Patients treated with the kERAS protocol showed less long-term CKD upstaging compared to those treated with the standard protocol (p = 0.0033). There was no significant effect on LOS and new onset of CKD.ConclusionThe implementation of a kERAS protocol can have a positive influence on long-term renal function in patients undergoing PN. It can be used safely without promoting AKI. Furthermore, it can be realized with a manageable amount of additional effort.

Pathological Insights into Non-Neoplastic Renal Parenchyma in Wilms Tumor: Implications for Nephron-Sparing Surgery.

This study aimed to evaluate the non-neoplastic renal parenchyma in Wilms tumor (WT) and investigate its impact on nephron-sparing surgery (NSS). The non-neoplastic renal parenchyma of WT patients was prospectively collected for pathological examination. The histology of non-neoplastic renal parenchyma was assessed from two perspectives: nephrogenic rests (NRs) and nephrons. A total of 46 non-neoplastic renal parenchyma specimens were collected from 42 WT patients. The surgeons assessed the median proportion of non-neoplastic renal parenchyma as 30%, whereas using ellipsoid volume, it was calculated to be 27%. The Youden index of surgeons' assessment peaked at a 15% proportion of non-neoplastic renal parenchyma. The bilateral WT (BWT) group and NSS group exhibited significant differences compared with the unilateral WT group and radical nephrectomy group, respectively, with the BWT group showing a tendency toward thickened basement membrane. The presence of NRs and endogenous nephron alternations should be given due attention in WT. The probability of abnormalities is low when the proportion of non-neoplastic renal parenchyma exceeds 15%, providing pathological support for expanding the adaptation of NSS.

A Case Report of Congenital Wilms’ Tumor and a Comprehensive Literature Review highlighting the spectrum between Wilms’ Tumor and Nephroblastomata’s

Abstract Introduction/Objective Wilms’ Tumour (WT) represents the most frequently encountered malignant renal neoplasm within pediatric pathology. To delineate the histopathological features of WT with perilobar nephrogenic rests (PLNR) and intralobar nephrogenic rests (ILNR) from nephroblastomatosis, we report a case with literature review to evaluate the clinical implications of WT with or without nephrogenic rests (NR), and nephroblastomatosis. Methods/Case Report Our patient is a 2-week-old neonate with VACTERL, germline mosaic triple X, and stage 1 WT with PLNR and substantial ILNR. The management approach involved radical nephrectomy exclusively. Obtaining a unifying clinical syndrome as well as deciding between WT or nephroblastomatosis was challenging in this case. The molecular testing with VACTERL panel was indeterminate and WT panel revealed DIS3L2 mutation that is indeterminate but likely pathogenic. She has been stable for 12 months and placed on 4-monthly left kidney ultrasound surveillance. Results (if a Case Study enter NA) Our literature review showed that the most common histologic subtype in WT patients without NR (n=59) and with NR (n=33) were classic triphasic (28.8%) and stromal-predominant (39.3%), respectively. WT patients with or without NR, underwent radical nephrectomy followed by adjuvant chemotherapy. Loss of heterozygosity (LOH) in TRIM28 was 4-fold higher in cases with NR. Mortality and relapse rates (12.5%) were higher in non-NR cohort. Conversely, nephroblastomatosis patients (n=14) underwent neoadjuvant chemotherapy, ipsilateral radical nephrectomy, and contralateral nephron-sparing surgery. Nephroblastomatosis patients had higher mortality (22.2%) and relapse rate (30%), with no identifiable mutations on molecular testing. Conclusion WT patients with NR have an earlier diagnosis and lower mortality and relapse rates compared to those without NR. The higher frequency of LOH in TRIM28 in WT patients with NR warrants future exploration to assess its implication in progression free survival. Nephroblastomatosis exhibits higher mortality and relapse rates, emphasizing the importance of reporting nephroblastomatosis in co-existing WT cases.

Application value of domestic single-port robot in nephron sparing surgery

Objective: To explore the application value of the domestic precision ®single-port robotic system in nephron sparing surgery. Methods: The clinical data of patients with renal masses underwent nephron sparing surgery using the domestic precision ®single-port robotic system at the PLA General Hospital, Gulou Hospital Affiliated to Nanjing University School of Medicine, Zhongnan Hospital of Wuhan University and the First Affiliated Hospital of Nanchang University from September to November 2023 were retrospectively included. Perioperative clinical data, pathological examination results, and postoperative complications were summarized. Results: A total of 12 patients were included, including 8 males and 4 females, with 26-75 (56±16) years. Body mass index (BMI) was (25.1±2.7) kg/m2. There were 6 cases on the left side and 6 case on the right side. The surgical approach was transabdominal in 9 cases and retroperitoneal in 3 case. The maximum diameter of the lesions was (2.7±0.7) cm, the warm ischemia time [M (Q1, Q3)] was 19 (15, 26) minutes, the surgical time was 180 (149, 216) minutes, and the intraoperative blood loss was 50 (28, 100) ml. Postoperative visual analogue scale (VAS) was (2.9±1.5) points. Postoperative pathology revealed malignant renal clear cell carcinoma in 9 cases, with nuclear grading of 3 cases for Grade 1, 3 cases for Grade 2, and 3 cases for Grade 3. Eight cases of pathological TNM staging were pT1aN0M0 and 1 case was pT3aN0M0, with no cancer at the resection margin. Three cases showed benign renal vascular smooth muscle lipoma. There were no postoperative blood transfusions and no complications such as fever, urine leakage and poor wound healing. Conclusion: The prliminary experience reveals that the domestic precision ®single-port laparoscopic robotic system has good clinical application value in urological nephron sparing surgery.

Nephronsparing surgery for retroperitoneal sarcomas

Objective: to clarify the indications for the use of nephron-sparing technologies in surgical treatment of patients with retroperitoneal sarcomas. Material and Methods. The study included 64 patients with primary retroperitoneal sarcomas with kidney and renal pedicle invasion, who underwent surgical treatment in the Thoracic-abdominal Department of the P.A. Herzen Moscow Oncology Research Institute from 2010 to 2021. Twenty-one patients underwent nephrectomies, and 43 patients underwent nephron-sparing surgery. The morphological profile of sarcomas, age and gender of the patients, feasibility of using nephron-sparing technologies, postoperative complications, and long-term outcomes in patients of both groups were analyzed. Results. Forty-three patients with primary retroperitoneal sarcomas with invasion of the renal parenchyma, ureter, and renal pedicle underwent nephron-sparing surgery (precision mobilization of the kidney, ureter and vascular structures of the kidney from tumor tissue, kidney resection, ureteral stenting, resection of the renal vein orifices, resection of the ureters, and kidney autotransplantation). Postoperative complications were observed in 19.0 % of nephrectomy group patients (4 pts: II, IIIB, IV and V types according to Clavien–Dindo) and in 30.2 % of nephron-sparing group patients (15 pts: types II – 8, IIIA – 1, IIIB – 3, IV – 1). No statistical differences in the relapse-free period and survival time between two groups were observed. The 1-, 3- and 5-year survival rates were 84.1 %, 65.9 %, and 51.4 %, respectively. Multifactorial analysis showed that mortality increased significantly in patients over 64 years of age and was associated with both disease recurrence and concomitant pathology (p=0.009). There was also a trend toward decreased survival in patients with leiomyosarcoma (p=0.066). Conclusion. In retroperitoneal sarcomas, tumor resection with preservation of organs and structures not directly invaded by the tumor is the optimal surgical strategy. Nephron-sparing technologies do not worsen both immediate and long-term treatment outcomes. For leiomyosarcoma, tumor resection with nephrectomy is the most suitable approach.

2018P Nephron-sparing surgery combined with perioperative systemic therapy in select high-risk upper tract urothelial carcinoma (UTUC) Patients: A pilot study for a prospective phase II trial

2018P Nephron-sparing surgery combined with perioperative systemic therapy in select high-risk upper tract urothelial carcinoma (UTUC) Patients: A pilot study for a prospective phase II trial

VE17 Robotic nephron-sparing surgery off-clamping in transplanted kidney

VE17 Robotic nephron-sparing surgery off-clamping in transplanted kidney

Intraoperative ultrasound-guided paediatric urological surgery: a pictorial review.

Intraoperative ultrasound is described widely in multiple pathological scenarios in adult practice and in image-guided interventions in children. We aim to describe the technique and range of potential uses of intraoperative ultrasound in paediatric urological surgery, from outlining the process of case selection, preparation, and logistics to demonstrating the ranging benefits of real-time, high spatial resolution ultrasound during resection. At our centre, we use intraoperative ultrasound to assist in a variety of operations. These include guiding excision margins in nephron-sparing surgery, assessing for vascular infiltration in renal tumours, and identifying salvageable testicular tissue in orchidectomy. By exhibiting these scenarios, we hope to display the unique value that intraoperative ultrasound can have to the paediatric surgeon and inspire additional uses further afield.

50 National trends in the surgical management of renal cell carcinoma in Germany

Abstract Background The incidence of RCC is increasing worldwide. For most patients with localized RCC, surgery remains the preferred treatment option. We aimed to investigate whether international trends towards minimally invasive procedures and nephron-sparing surgery are reflected in Germany. Methods Pseudonymized inpatient billing data from the AOK (Allgemeine Ortskrankenkassen), a non-profit oriented health insurance organization in Germany, was used for the conduct of the study. A total of 43,936 RCC cases were identified in which either a partial nephrectomy (PN, n = 20,030) or radical nephrectomy (RN, n = 21,906) was performed between 2012 and 2021. The proportions of different surgical procedures over time, as well as mortality (90 days), transfusion rate, reinterventions, and general postsurgical complications (30 days), were evaluated. Due to the use of pseudonymized data, no ethics vote was required. Results During the period of observation, there was a significant shift from RN to PN, with an increase in the proportion of PN among all procedures from 41.0% (1,918/4,684) in 2012 to 57.4% (2,274/3,960) in 2021 (p <0.001). Open surgery decreased for PN and RN but still accounted for the majority of all procedures (2021: 53.2% of PN and 65% of RN). Mortality was higher among patients with RN compared to PN (in hospital: 1.9% vs. 0.6%, 90 days: 4.7% vs. 1.2%). While general complication rates were similar (19.4% after PN versus 20.4% after RN), the reintervention rate was slightly higher after PN at 10.7% than after RN at 7.9%. Transfusion rates decreased significantly in several subgroups, favoring PN and minimally invasive approaches. Open surgical procedures were associated with higher unadjusted complication rates. Conclusions Despite shifts in favor of nephron-sparing surgery and minimally invasive surgery during the study period, open surgery remained the dominant surgical option for the treatment of renal cell carcinoma in Germany as of 2021. The adoption of laparoscopic and robotic-assisted techniques appears to reduce overall perioperative morbidity and consequently improve the quality of care in Germany. Further studies are required to examine patient level trends between type of surgical procedure, complication rates, and oncologic outcomes. Optimizing the assessment of the quality of care would enable further improvement of the quality itself.

23 Pre-surgical visceral adipose tissue may be a novel pre-surgical risk factor for acute kidney injury among clear cell renal cell cancer patients undergoing radical nephrectomy

Abstract Background Patients with renal cancer undergoing partial (PN) or radical nephrectomy (RN) are at risk for acute kidney injury (AKI). Established risk factor for AKI include baseline comorbidities (e.g., obesity, hypertension), normal renal parenchymal loss, and ischemia-reperfusion injury. Pre-surgical body composition may be an overlooked modifiable patient characteristic that influences risk of AKI. We hypothesized that patients with higher visceral adipose tissue quantity or lower skeletal muscle quantity would have a higher risk of AKI. Methods The RESOLVE study at Memorial Sloan Kettering Cancer Center is a retrospective study of 1239 patients with stage I-III clear cell renal cell carcinoma (ccRCC) undergoing PN or RN from 2000 to 2020. We excluded from analysis patients with solitary kidney, those without preoperative serum creatinine (sCr) measurements, and those without a sCr measurement within seven days following nephrectomy, yielding a study population of 1,200 ccRCC patients with longitudinal sCr assessment (n=754 PN; n=446 PN). AKI was defined as a binary variable using the Kidney Disease – Improving Global Outcomes (KDIGO) criteria, based on a threshold of either a 1.5x relative or 0.3 mg/dl absolute increase in sCr within seven days. The cross-sectional areas and radiodensities of visceral adipose and skeletal muscle tissues were determined from pre-surgical computed tomography (CT) scans at the third lumbar vertebrae using Automatica software. We used generalized linear models with a binomial family and identity link to estimate seven-day risk differences (RD) and 95% confidence intervals in subgroups defined by surgery type. Results AKI was more frequent among patients undergoing RN (66% vs 26% among PN). Male patients, those with higher eGFR prior to surgery, those with lower stage/smaller tumors, and those with a history of hyperlipidemia more frequently experienced AKI in the post-operative period. No associations were observed with other reported comorbidities (diabetes, hypertension). While no association was observed between BMI and risk of AKI, visceral adipose and skeletal muscle variables were significantly associated with risk of AKI in univariate models. After adjustment for age, sex, comorbidities, and other body composition variables, only higher visceral adipose tissue quantity remained significantly associated with increased risk of AKI [RD per 40 unit increase (95% CI): 5.2 (1.3, 9.2)]. Muscle characteristics were not associated with AKI in multivariable models. Among patients undergoing PN, we observed a higher frequency of AKI among male patients, those with higher stage/larger tumors, and those with longer ischemia times. No significant associations were observed with comorbidity histories. In univariate models, visceral adipose tissue quantity and quality as well as skeletal muscle quantity were associated with AKI risk; however, after adjustment for age, sex, comorbidities, and other body composition variables, we observed no significant associations between any body composition feature and AKI in patients undergoing PN. Conclusions Associations between pre-surgical body composition and risk of AKI vary by surgery type. Visceral adipose tissue quantity was associated with risk of AKI among patients undergoing RN, but not PN. This finding may be relevant for patient counseling, consideration for nephron-sparing surgery, and development of interventions to lower visceral adipose tissue quantity. Future studies should evaluate the impact of both pre-surgical and post-surgical change in body composition in relation on chronic kidney disease after nephrectomy.

Variability in Kidney Cancer Treatment and Survival in England: Results of a National Cohort Study

AimsTo establish whether there are geographic differences in treatments and outcomes for patients with kidney cancer (KC) in England which could potentially be improved by the creation of national guidelines. Materials and methodsA multidisciplinary group convened by the charity Kidney Cancer UK developed Quality Performance Indicators (QPIs) for the treatment of KC. Adherence to these QPIs was reported for all patients with a histological diagnosis of KC diagnosed in England between 2017 and 2018. Utilising data extracted from national datasets, logistic and linear probability models were used to estimate geographic variation in the delivery of surgery and systemic anti-cancer therapy at Cancer Alliance and NHS trust levels. Results were adjusted for a priori confounders, including age at diagnosis, area deprivation of residence, and Charlson Comorbidity Index. Differences in overall survival are reported. ResultsThe cohort comprised 18,640 tumours in 18,421 patients. Of tumours diagnosed, median patient age was 68 (interquartile range 58–77) years and 63.4% were in males. When stratified by Cancer Alliance, the proportions of T1a/T1b/N0/M0 KC that had radical nephrectomy (RN), nephron sparing surgery or ablation ranged from 53.3% (95% CI [48.7, 57.8]) to 80.3% (95% CI [73.0, 86.0]). For stage T1b-3 cancers, the proportion that received RN ranged from 65.6% (95% CI [60.3, 70.5]) to 77.3% (95% CI [72.1, 81.7]). Patients with M0 (n = 12,365) and M1 KC (n = 3312) at diagnosis had 24-month survival of 87.5% and 25.1%, respectively. Of patients diagnosed with M1 KC, 50.3% received systemic anti-cancer therapy, ranging from 39.7% (95% CI [33.7, 46.1]) to 70.7% (95% CI [59.6, 79.8]) between Cancer Alliances. The six-month survival of these patients was 77.4% compared to 27.6% for those that did not receive SACT. ConclusionThese major geographical differences in surgical and systemic therapy practice have led to national guideline development.

Evolving Approach in Nephron-Sparing Surgery: Has Anything Changed from Open Surgery to Laparoscopy?

This study aimed to provide valuable insights into the comparative efficacy of different surgical approaches for nephron-sparing surgery (NSS) and contribute to the existing literature in this field. This study included patients who underwent NSS for small renal masses between January 2016 and March 2024. A total of 97 patients (41 in the open approach group, 56 in the laparoscopic approach group) with demographic, radiological, intraoperative, renal functional, and oncological follow-up data were included. Three different anatomical scoring systems (R.E.N.A.L. nephrometry score, PADUA score and C-index) were utilised to assess tumour location and estimate proximity to the hilum and collecting system. In the open nephron-sparing surgery (ONSS) and laparoscopic nephron-sparing surgery (LNSS) groups, the mean kidney tumour diameters (SD) were 5.20 ± 2.30 and 4.90 ± 2.10, which were similar in both surgical method groups (p = 0.061). However, tumours treated with ONSS had significantly more adverse morphometric features (p < 0.05). For ONSS and LNSS groups, the mean R.E.N.A.L. nephrometry scores (SD) were 6.15 ± 2.04 and 5.2 ± 1.4 (p = 0.032), respectively; The mean PADUA scores (SD) were 7.46 ± 1.14 and 6.8 ± 1.0 (p = 0.049), respectively; And the mean C-index (SD) scores were 1.39 ± 0.4 and 1.37 ± 0.5 (p = 0.062), respectively. No significant differences were found in the mean tumour diameter (cm) (Inter Quantile Range (IQR)) distribution of both groups (p = 0.058). Despite the slight increase in transfusion rate in the LNSS group, estimated blood loss (EBL), transfusion rates, and length of hospital stay were similar in both groups. Although LNSS does not appear superior in terms of intraoperative blood loss, length of hospital stay and transfusion rate, it provides comparable long-term outcomes to ONSS. Our study suggests that when matched with nephrometry scores, LNSS can achieve similar outcomes to ONSS.

Does bilateral Wilms’ tumor involving the collecting system in children have a worse prognosis?

BackgroundThe literature on nephron-sparing surgery (NSS) in children with bilateral Wilms’ tumors (BWT) involving the collection system is mostly comprised of case reports. The present study aimed to summarize the clinical characteristics, treatments, and prognosis of children with BWT involving the collecting system admitted to our pediatric surgery center compared with those whose tumors did not involve the collecting system. A secondary aim was to discuss how to preserve more kidney parenchyma and prevent long-term renal failure under the premise of preventing tumor recurrence.MethodsPatients with BWT admitted to our pediatric surgery center between January 2008 and June 2022 were reviewed. All included patients were grouped according to the relationship between the tumor and collecting system according to the intraoperative findings. Group I included children with tumor infiltrating the collecting system, group II included children with tumor growing into the collecting system, and group III included children whose tumor did not involve the collecting system. The clinical features, treatments and prognosis of the patients were analyzed.ResultsSeventy patients were enrolled, including 20 patients with 25 sides of tumors infiltrating the collecting system in group I,10 patients with 13 sides of tumors growing into the collecting system in group II, and 40 patients in group III. There was no significant difference in patients age and gender between group I and group II. In total, 20 patients in group I and 9 patients in group II had partial response (PR) after neoadjuvant chemotherapy. In group I, 22 of 25 sides of tumors underwent NSS; in group II, 11 of 13 sides of tumors underwent NSS. During an average follow-up of 47 months, in group I, 6/20 patients relapsed and 2/20 patients died; in group II, 3/10 patients relapsed and 1/10 patient died. There was no significant difference in 4-year overall survival (OS) rate among groups I, II and III (86.36% vs. 85.71%vs. 91.40%, P = 0.902).ConclusionsTo preserve renal parenchyma, NSS is feasible for children with BWT involving the collecting system. There was no significant difference in postoperative long-term OS between patients with BWT involving the collecting system and not involving the collecting system.

Reoperation for ipsilateral local recurrence following prior nephron-sparing surgery: innovative surgical insights from a high-volume urological center with cross-sectional study.

The main aim of this study was to examine the perioperative results of reoperations and suggest novel surgical approaches. Based on a substantial number of robotic and laparoscopic nephron-sparing surgery (NSS), we aim to propose novel surgical strategies that offer practical recommendations to surgeons. Renal cell carcinoma patients with ipsilateral recurrent tumors, without evidence of metastasis, and who underwent primary NSS at our center between 2013 and 2023 were enrolled in this study, and all received the second time surgery. We conducted an analysis to evaluate perioperative outcomes and observed trends over a decade. Additionally, based on the findings from this study, we developed our surgical strategies. In the past decade, our center has successfully conducted a total of 2546 surgeries for renal cell carcinoma, out of which this study includes 15 patients who met the specified criteria. For reoperation, robotic-assisted surgery was applied in 5 cases (33.3%), laparoscopic surgery in 6 cases (40%), and open surgeries in 4 cases (26.7%). While 4 (26.7%) patients underwent NSS while radical nephrectomy was performed on 11 patients (73.3%). The median operative time was 215 minutes (IQR: 135-300), and the median estimated blood loss was 50ml (IQR: 50-100). The median length of postoperative hospitalization was 6 days (IQR: 5-9). Furthermore, there has been a yearly increase in the application of robotic-assisted NSS at our institution. Reoperation following the pNSS is a secure and effective surgical approach. We introduce novel surgical strategies for primary surgery and reoperation, which offer valuable insights to surgeons in current study.

Wilms tumor characteristics, surgical management, outcomes, and chronic kidney disease in children with WAGR syndrome: A report from the International WAGR Syndrome Association survey.

Children with WAGR (Wilms tumor, aniridia, genitourinary anomalies, and range of development delays) syndrome are predisposed to Wilms tumor (WT) and intrinsic kidney disease. Using the comprehensive International WAGR Syndrome Association (IWSA) survey of children with WAGR syndrome, we analyzed tumor characteristics, treatment and congenital risk factors, and kidney function in children with WAGR and WT. Descriptive statistics were utilized including demographics, treatment strategies, and patient outcomes. Comparisons were made between patients with WAGR and WT to those with WAGR alone. A multivariable logistic regression was completed for risk of developing WT and to identify predictors of chronic kidney disease (CKD). Sixty-four of 145 children with WAGR developed WT (44.1%). Three relapsed and one died. CKD developed in five children with WAGR without WT (5/81, 6.2%), and in 34 with WAGR and WT (34/64, 28.3%). Children with WAGR and WT were younger (p=.017), and had a greater association with CKD than WAGR children without WT (p<.0001). Two children with WT required hemodialysis, and one underwent kidney transplantation. By univariate analysis, CKD at any stage was associated with complete nephrectomy for the WT surgery (p<.0001), chemotherapy duration greater than 12months, and three-drug therapy. Upon multivariate analysis, prior nephrectomy was the only significant variable (p=.0002). Epidemiological analysis of children with WAGR demonstrated favorable oncologic outcomes, but high rate of early CKD in those who developed WT. Further study of the use of nephron-sparing surgery in children with WAGR and strategies to delay or treat early CKD are needed.

Tracing the evolving dynamics and research hotspots in the kidney neoplasm and nephron sparing surgery field from the past to the new era

AbstractBackgroundWith increasing detection of small renal masses and accumulating evidence that nephron sparing surgery (NSS) could achieve oncological equivalence and functional superiority compared with radical nephrectomy (RN), NSS has become first‐line therapy for some patients with localized renal masses.ObjectiveThis study aims to review the publications in the kidney neoplasm and NSS field, exploring the research hotspots.MethodKidney neoplasm and NSS related publications before July 3th 2023 were obtained from the Web of Science Core Collection database. We then used bibliometric analysis to conduct performance analysis, citation analysis and co‐citation network of publications, together with keyword co‐occurrence analysis.ResultsSeven thousand five hundred and sixty‐four documents were finally retrieved, and the annual publications increased exponentially. The most productive authors were “KAOUK JH” and “GILL IS”, while USA, and 12 American affiliations such as CLEVELAND CLINIC FOUNDATION and MAYO CLINIC were far leading in this field. Journal of Urology and European Urology were journals with the highest citations and h‐index.DiscussionThrough literature reviewing plus co‐occurrence and clustering analysis, the therapeutic effects of partial nephrectomy (PN) versus RN on patients with localized renal cell carcinoma, different operative approaches of PN, and conservative NSS methods were deemed as the most focused topics.ConclusionThree aspects were the most important hotspots in this field. Firstly, how to provide the optimal management choices for different patients. Secondly, therapeutic effects of different management options and surgical techniques needed more prospective and randomized studies. Finally, more novel technologies and surgical techniques were required.

Laparoscopic nephron-sparing surgery for complex renal cystic lesions: a single-center experience.

This study aimed to explore the feasibility and safety of laparoscopic nephron-sparing surgery (LNSS) for complex renal cystic lesions. A retrospective study was conducted on 83 cases of complex renal cystic lesions treated with LNSS in our hospital. There were 32 men and 51 women, ranging in age from 24 to 73years (average, 47.22±9.03years). The diameter of the cysts was 1.5-5.9cm (average, 3.44±0.86cm). According to the Bosniak classification, there were 15 cases of type II, 23 cases of type IIF, 29 cases of type III, and 16 cases of type IV complex renal cystic lesions. According to clinical classification based on the difficulty of laparoscopic partial nephrectomy and the depth of the lesion, the 83 complex renal cystic lesions were divided into 48 cases of the extra-renal type, 15 cases of the centrally located type, seven cases of the renal sinus type, and 13 cases of the renal hilum type. Laparoscopic partial nephrectomy was successful in all 83 patients. The surgical time was 35-102min (average, 52.13±14.38min), the intraoperative bleeding volume was 10-200ml (average, 27.25±12.26ml), and the renal artery occlusion time was 12-28min (average, 12.46±4.45min). There was no significant change in creatinine before and after surgery. The postoperative pathological results showed 71 cases of renal clear cell carcinoma, five cases of low malignant potential multilocular cystic renal tumors, and seven cases of pure renal cysts with all margins negative. There is potential for the malignant transformation of complex renal cysts into renal cell carcinoma. For complex renal cysts classified as Bosniak IIF or higher, surgical intervention is recommended, and LNSS is safe and effective. The complexity of the surgical procedure varies depending on the location classification of the complex renal cysts.

#2508 Urinary [TIMP-2]*[IGFBP7] as the ultimate potential biomarker of subclinical Acute Kidney Injury after kidney surgery: a multicentric study

Abstract Background and Aims Nephron-sparing surgery (NSS) represents the preferred technique to treat localized renal lesions and better preserve kidney function. Still it is not exempted from the risk of postoperative acute kidney injury (AKI) to happen, with a reported incidence ranging from 5.5% to 34%. Patients experiencing postoperative AKI, either clinical or subclinical, are more susceptible to chronic kidney disease (CKD). The latter represents a difficult-to-identify subpopulation characterized by tubular damage biomarker's rising without changes in serum creatinine (scr), that after surgery is less likely to be included among the ones deserving a closer follow-up, but actually needing one, as this subpopulation's long term outcomes slightly differ from individuals recovered from clinical postoperative AKI. This is the reason why a standardized tool for early identification of patients suffering from subclinical AKI is required, to allow a customized postoperative surveillance, promote strategies of nephroprotection and reduce the incidence of CKD and end-stage kidney disease. Recent evidences show that by exclusively following outdated consensus criteria for AKI (changes in scr, urine output), 15-20% of patients undergoing through acute tubular injury and suffering from its adverse outcomes are likely to be missed. Only recently, FDA approved NephroCheck® biomarker, which combines two urinary markers, tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7). It represents the first effective test for AKI's risk assessment. In a previous monocentric study [1], our group presented NephroCheck® as a biomarker able to efficiently identify subclinical AKI and predict long-term eGFR decline after robotic NSS. In order to confirm our previous results, we recruited a larger cohort and performed a multicentric study. Method We prospectively observed all patients scheduled for robotic NSS in suspected localized renal cell carcinoma in two different Centers from 2016 to 2018. Samples were collected preoperatively and postoperatively (4 h, 10 h, 24 h, 48 h), while kidney function was re-assessed up to 24 months. A multivariate logistic analysis was performed to evaluate the association between different parameters and eGFR decline at 24 months. Results A total number of 131 patients were included; 55/131 (42%) developed clinical AKI. A significant association between NephroCheck® at 4 h and clinical AKI, as stated by KDIGO Guidelines, is confirmed (p = 0.0055). In the overall cohort, the multivariate analysis shows that only clinical AKI appears as an independent factor for predicting eGFR decline at 24 months (p &amp;lt; 0.0003), while postoperative NephroCheck® alone did not (p = 0.92). Based on NephroCheck® measured 4 h after surgery and clinical AKI, patients can be divided in four groups with significantly different eGFR at 24 months (p = 0.0003) (Fig. 1). Not considering patients who experienced clinical AKI, the independent role of different parameters in predicting severe eGFR decline at 24 months was evaluated by multivariate logistic analysis; in this subgroup of patients, NephroCheck® evaluated at 4 h postoperatively appears as an independent factor able to predict a severe eGFR decline at 24 months (OR 3.76, p = 0.02) (Fig. 2). Conclusion NephroCheck®, in combination with scr, represents an accurate and easy-to-use test, likely able to early identify long-term eGFR decline in patients undergoing NSS surgery that don't develop a clinically evident postoperative AKI (subclinical AKI), making it possible to identify those in need of closer-up surveillance, reducing the incidence and progression of CKD. Still, clinical postoperative AKI is confirmed as the most important prognostic parameter and predictive factor for eGFR decline in the long-term. Further studies are needed, particularly focusing on application of NephroCheck® in setting other than NSS.