Small Renal Masses Research Articles

Possible treatments for synchronous bilateral small renal masses

Currently, there is no established consensus on the best treatment approach for patients with bilateral synchronous renal masses (BSRM). The timing and method of managing these cases remain subjects of debate. This review aims to summarize the available literature and explore the ongoing controversies surrounding this topic. Three studies investigated non-surgical treatments within BSRM. Specifically, one study focused on active surveillance (AS) and showed no statistical differences in terms of progression and development of metastatic disease relative to their unilateral counterpart. Two studies investigated ablative techniques showing promising results. Eight papers have been published regarding robot assisted partial nephrectomy (RAPN) for BSRM. All these papers highlighted the safety, feasibility, and efficacy of bilateral RAPN for BSRM. Literature regarding treatments other than surgery such as AS and ablative therapies (ATs) for BSRM is scarce, but promising. Progression, rate of metastases and survival of BSRM are similar to unilateral disease, and AS is a safe option in these cases. Few studies focused on RAPN related outcomes for BSRMs, but all confirmed the safety, feasibility, and efficacy of this procedure. Finally, one step RAPN resulted as feasible as the two staged procedures, especially when selective clamping techniques can be chosen.

Small renal mass: which criteria are decisive for a tumor board?

Small renal masses (SRM) are aheterogeneous group of tumors with varying metastatic potential. The increasing use and improvement in the quality of abdominal imaging have led to an increasingly earlier diagnosis of incidental SRM, which are asymptomatic and confined to the organ. Despite these advances in imaging and the growing use of renal tumor biopsies, preoperative diagnosis of malignancy remains difficult. The treatment of SRM has shifted away from radical nephrectomy and now primarily includes organ-sparing surgery or active surveillance. The optimal strategy for treating SRM is continuously evolving as studies from prospective data registries can identify factors that influence both short- and long-term patient outcomes. Recent research on biomarkers, imaging techniques, and machine learning offer promising approaches to adeeper understanding of tumor biology and treatment options for this patient population.

[89Zr]Zr-girentuximab PET-CT imaging to diagnose, characterize, and differentiate clear-cell renal cell carcinoma

In the phase 3 ZIRCON trial, [89Zr]Zr-girentuximab positron emission tomography-computed tomography (PET-CT) detected the presence of clear-cell renal cell carcinoma (ccRCC) with a sensitivity of 86% and a specificity of 87% in patients with an indeterminate renal mass undergoing nephrectomy.1 This imaging technique could be a promising tool that could revolutionize the management of small renal masses (SRMs) and ccRCC.

P193 Long term oncological outcomes following percutaneous microwave ablation of small renal masses

P193 Long term oncological outcomes following percutaneous microwave ablation of small renal masses

Diagnostic Value of Contrast-Enhanced Ultrasound in Differentiating Malignant from Benign Small Renal Masses After CT/MRI.

Background: The aim of this study was to assess the diagnostic performance of contrast-enhanced ultrasound (CEUS) in characterizing small renal masses (SRMs) measuring less than 3 cm and in distinguishing between malignant and benign SRMs. Methods: A retrospective study was conducted between January 2022 and January 2023 at the Radiology Department of (Anonymized data), with a total of 43 patients assessed via CT and MRI scans, which were subsequently studied by experienced radiologists who were blinded to the pathology results. The CEUS findings were then compared with histopathological examination outcomes or follow-up imaging results. Results: The study results revealed a notably high level of diagnostic accuracy, with sensitivity at 0.875, specificity at 0.94, positive predictive value at 0.95, and negative predictive value at 0.86 for characterizing SRMs. Spearman rank correlation analysis substantiated a robust positive linear correlation between the CEUS findings and biopsy results (r = 0.972). Conclusions: These findings underscore the potential utility of CEUS as a valuable tool for discriminating between malignant and benign SRMs, carrying significant implications for clinical decision-making and leading to improved patient outcomes. However, larger validation studies are imperative to establish its role in routine clinical practice and to address potential limitations.

Single-Port Versus Multi-Port Robotic Retroperitoneal Partial Nephrectomy: A Propensity Score-Matched Comparison.

Objective: To compare the surgical results of retroperitoneal (RP) robot partial nephrectomy (PNx) using either a single-port robot (SP) or a multi-port robot (MP). Materials and Methods: We retrospectively reviewed all RP robotic PNx performed at a single institution from September 2021-when the SP robot was introduced to the institution-through April 2023. In total, 125 patients underwent the surgery; 81 patients were treated with surgery using a MP robot whereas 44 patients were treated with surgery using a SP. All MP surgeries were performed with da Vinci Xi (Intuitive, Sunnyvale, California, USA), while all SP surgeries were performed with da Vinci SP (Intuitive, Sunnyvale, California, USA). We performed a propensity score-matching (PSM) analysis of these 125 patients. Results: There was no significant difference between the two groups after PSM. In terms of operation time, that for MP was 103.68 ± 21.89 minutes whereas that for SP was 95.43 ± 32.22 minutes (p-value = 0.164). Meanwhile, in terms of console time, that for MP was 70.95 ± 21.92 minutes whereas that for SP was 64.14 ± 32.06 minutes (p-value = 0.248). In terms of estimated blood loss was 90.91 ± 91.06 mL in MP and 92.27 ± 104.30 mL in SP (p-value = 0.948). Lastly, there was a statistically significant difference in warm ischemic time, as it was 17.18 ± 6.56 minutes in MP and 13.82 ± 4.59 in SP (p-value = 0.007). There were no statistically significant differences between MP and SP in any other surgical outcomes. Conclusions: SP robot RP PNx demonstrated comparable outcomes to those achieve using MP procedures. This means SP robot RP PNx can be considered a preferable and more convenient surgical approach than conventional methods, particularly when dealing with small renal masses located in the posterior side of the kidney.

Radiomics-based machine learning role in differential diagnosis between small renal oncocytoma and clear cells carcinoma on contrast-enhanced CT: A pilot study

PurposeTo investigate the potential role of radiomics-based machine learning in differentiating small renal oncocytoma (RO) from clear cells carcinoma (ccRCC) on contrast-enhanced CT (CECT). Material and methodsFifty-two patients with small renal masses who underwent CECT before surgery between January 2016 and December 2020 were retrospectively included in the study. At pathology examination 39 ccRCC and 13 RO were identified. All lesions were manually delineated unenhanced (B), arterial (A) and venous (V) phases. Radiomics features were extracted using three different fixed bin widths (bw) of 25 HU, 10 HU, and 5 HU from each phase (B, A, V), and with different combinations (B+A, B+V, B+A+V, A+V), leading to 21 different datasets. Montecarlo Cross Validation technique was used to quantify the estimator performance. The final model built using the hyperparameter selected with Optuna was trained again on the training set and the final performance evaluation was made on the test set. ResultsThe A+V bw 10 achieved the greater median (IQR) balanced accuracy considering all the models of 0.70 (0.64–0.75), while A bw 10 considering only the monophasic ones. The A bw 10 model achieved a median (IQR) sensitivity of 0.60 (0.40–0.60), specificity of 0.80 (0.73–0.87), AUC-ROC of 0.77 (0.66–0.84), accuracy of 0.75 (0.70–0.80), and a Phi Coefficient of 0.38 (0.20–0.47). None of the nine models with the lowest mean balanced accuracy values implemented features from A. ConclusionThe A bw 10 model was identified as the most efficient mono-phasic model in differentiating small RO from ccRCC.

Is there enough evidence supporting the clinical adoption of clear cell likelihood score (ccLS)? An updated systematic review and meta-analysis

ObjectiveTo review the evidence for clinical adoption of clear cell likelihood score (ccLS) for identifying clear cell renal cell carcinoma (ccRCC) from small renal masses (SRMs).MethodsWe distinguished the literature on ccLS for identifying ccRCC via systematic search using PubMed, Embase, Web of Science, China National Knowledge Infrastructure, and Wanfang Data until 31 March, 2024. The risk of bias and concern on application was assessed using the modified quality assessment of diagnostic accuracy studies (QUADAS-2) tool. The level of evidence supporting the clinical adoption of ccLS for identifying ccRCC was determined based on meta-analyses.ResultsEight MRI studies and three CT studies were included. The risk of bias and application were mainly related to the index test and flow and timing, due to incomplete imaging protocol, unclear rating process, and inappropriate interval between imaging and surgery. The diagnostic odds ratios (95% confidence intervals) of MRI and CT ccLS were 14.69 (9.71–22.22; 6 studies, 1429 SRM, 869 ccRCC), and 5.64 (3.34–9.54; 3 studies, 296 SRM, 147 ccRCC), respectively, for identifying ccRCC from SRM. The evidence level for clinical adoption of MRI and CT ccLS were both rated as weak. MRI ccLS version 2.0 potentially has better diagnostic performance than version 1.0 (1 study, 700 SRM, 509 ccRCC). Both T2-weighted-imaging with or without fat suppression might be suitable for MRI ccLS version 2.0 (1 study, 111 SRM, 82 ccRCC).ConclusionccLS shows promising diagnostic performance for identifying ccRCC from SRM, but the evidence for its adoption in clinical routine remains weak.Critical relevance statementAlthough clear cell likelihood score (ccLS) demonstrates promising performance for detecting clear cell renal cell carcinoma, additional evidence is crucial to support its routine use as a tool for both initial diagnosis and active surveillance of small renal masses.Key PointsClear cell likelihood score is designed for the evaluation of small renal masses.Both CT and MRI clear cell likelihood scores are accurate and efficient.More evidence is necessary for the clinical adoption of a clear cell likelihood score.Graphical

Length of hospital stay and procedure time after partial nephrectomy or percutaneous thermal ablation: A systematic review and meta-analysis.

This systematic review addressed the length of hospital stay (LOS) and procedure time in patients with small renal masses (SRM) undergoing open, conventional laparoscopic (OPN), and robot-assisted partial nephrectomy (RAPN), as well as percutaneous thermal ablation (PTA) in different geographic areas. We conducted a comprehensive search in databases (MEDLINE, EMBASE, CINAHL) until July 2023, and we applied random-effect meta-analysis, with evidence certainty assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. We screened 3456 titles and abstracts, ultimately identifying 60 eligible studies. For the length of LOS (days) following OPN, our pooled estimates revealed means of 5.7 in North America, 7.1 in Europe, and 13.4 in Asia; following laparoscopic partial nephrectomy, means were 3.1, 5.4, and 5.8, respectively; for RAPN, means were 2.7, 3.8, and 7.1; and for PTA, means were 1.2, 1.6, and 1.6. Regarding procedure time (minutes) after OPN, means were 187 in North America, 132 in Europe, and 184 in Asia; after laparoscopic partial nephrectomy, means were 198, 127, and 200; after RAPN, means were 189, 150, and 192; and for PTA, mean was 144 in North America and no studies addressed procedure time in Europe and Asia. Our study provides the most trustworthy available estimates of LOS and procedure time for patients undergoing invasive procedures for the management of SRM. These findings have emphasized the need for context-specific considerations when informing patients and making treatment decisions.

Indian consensus statements on the management of small renal masses, non-muscle invasive bladder cancer and high-risk/locally advanced prostate cancer.

No pan-India-specific guidelines exist for the management of urological cancers. Although western guidelines are useful for informing management strategies, they do not account for the nuances of management in the Indian context. A modified Delphi method was used to provide a framework for the systematic development of India-centric guidelines for the management of three uro-oncology disease states: small renal masses, non-muscle invasive bladder cancer and high-risk/locally advanced prostate cancer.

Cost-effectiveness analysis of microwave ablation versus robot-assisted partial nephrectomy for patients with small renal masses in Australia

ObjectivesMicrowave ablation (MWA) has gained attention as a minimally invasive and safe alternative to surgical intervention for patients with small renal masses; however, its cost-effectiveness in Australia remains unclear. This study conducted a cost-effectiveness analysis to evaluate the relative clinical and economic merits of MWA compared to robotic-assisted partial nephrectomy (RA-PN) in the treatment of small renal masses. MethodsA Markov state-transition model was constructed to simulate the progression of Australian patients with small renal masses treated with MWA versus RA-PN over a 10-year horizon. Transition probabilities and utility data were sourced from comprehensive literature reviews, and cost data were estimated from the Australian health system perspective. Life-years, quality-adjusted life-years (QALYs), and lifetime costs were estimated. Modelled uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. A willingness-to-pay (WTP) threshold of $50,000 per QALY was adopted. All costs are expressed in 2022 Australian dollars and discounted at 3% annually. To assess the broader applicability of our findings, a validated cost-adaptation method was employed to extend the analysis to 8 other high-income countries. ResultsBoth the base case and cost-adaptation analyses revealed that MWA dominated RA-PN, producing both lower costs and greater effectiveness over 10 years. The cost-effectiveness outcome was robust across all model parameters. Probabilistic sensitivity analyses confirmed that MWA was dominant in 98.3% of simulations at the designated WTP threshold, underscoring the reliability of the model under varying assumptions. ConclusionFor patients with small renal masses in Australia and comparable healthcare settings, MWA is the preferred strategy to maximize health benefits per dollar, making it a highly cost-effective alternative to RA-PN.

Differences in the treatment patterns of small renal masses: A disaggregated analyses by race/ethnicity

ObjectiveTo characterize differences in the management of small renal masses among disaggregated race/ethnic subgroups. Material and MethodsWe used the National Cancer Database to identify patients diagnosed with clinically localized kidney cancer and tumor size ≤4cm. We studied 16 predefined racial/ethnic subgroups and compared 1) the use of surveillance for tumors <2cm and 2) the use of radical nephrectomy for tumors ≤4cm. We used multivariable logistic regression to evaluate the independent association of race/ethnicity with management, adjusting for baseline characteristics. We also compared our disaggregated analyses to the 6 National Institute of Health aggregate race categories. ResultsWe identified 286,063 patients that met inclusion criteria. For tumors <2cm, Black Non-Hispanic (aOR 1.43) and Mexican patients (aOR 1.29) were significantly more likely to undergo surveillance compared to White patients. For tumors ≤4cm, Black Non-Hispanic (aOR 1.43), Filipino (aOR 1.28), Japanese (aOR 1.28), Mexican (aOR 1.32), and Native Indian patients (aOR 1.15) were significantly more likely to undergo radical nephrectomy compared to White patients. When comparing our disaggregated analyses to the NIH categories, we found that many disaggregated race/ethnic subgroups had associations with management strategies that were not represented by their aggregated group. ConclusionsIn this study, we found that the use of surveillance for tumors <2cm and radical nephrectomy for tumors ≤4cm varied significantly among certain race/ethnic subgroups. Our disaggregated approach provides information on differences in treatment patterns in particular subgroups that warrant further study to optimize kidney cancer care for all patients.

Imaging in Renal Cell Carcinoma Detection.

Imaging in renal cell carcinoma (RCC) is a constantly evolving landscape. The incidence of RCC has been rising over the years with the improvement in image quality and sensitivity in imaging modalities resulting in "incidentalomas" being detected. We aim to explore the latest advances in imaging for RCC. A literature search was conducted using Medline and Google Scholar, up to May 2024. For each subsection of the manuscript, a separate search was performed using a combination of the following key terms "renal cell carcinoma", "renal mass", "ultrasound", "computed tomography", "magnetic resonance imaging", "18F-Fluorodeoxyglucose PET/CT", "prostate-specific membrane antigen PET/CT", "technetium-99m sestamibi SPECT/CT", "carbonic anhydrase IX", "girentuximab", and "radiomics". Studies that were not in English were excluded. The reference lists of selected manuscripts were checked manually for eligible articles. The main imaging modalities for RCC currently are ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). Contrast-enhanced US (CEUS) has emerged as an alternative to CT or MRI for the characterisation of renal masses. Furthermore, there has been significant research in molecular imaging in recent years, including FDG PET, PSMA PET/CT, 99mTc-Sestamibi, and anti-carbonic anhydrase IX monoclonal antibodies/peptides. Radiomics and the use of AI in radiology is a growing area of interest. There will be significant change in the field of imaging in RCC as molecular imaging becomes increasingly popular, which reflects a shift in management to a more conservative approach, especially for small renal masses (SRMs). There is the hope that the improvement in imaging will result in less unnecessary invasive surgeries or biopsies being performed for benign or indolent renal lesions.

Microwave vs radiofrequency ablation for small renal masses: perioperative and oncological outcomes.

To conduct a comprehensive comparison of microwave ablation (MWA) vs radiofrequency ablation (RFA) outcomes in the treatment of small renal masses (SRMs), specifically: TRIFECTA ([i] complete ablation, [ii] absence of Clavien-Dindo Grade ≥III complications, and [iii] absence of ≥30% decrease in estimated glomerular filtration rate) achievement, operative time (OT), and local recurrence rate (LRR). We retrospectively analysed 531 patients with SRMs (clinical T1a-b) treated with MWA or RFA at a single centre (2008-2022). First, multivariable logistic regression models were used for testing TRIFECTA achievement. Second, multivariable Poisson regression models were used to evaluate variables associated with longer OT. Finally, Kaplan-Meier plots depicted LRR over time. All analyses were repeated after 1:1 propensity score matching (PSM). Of 531 patients with SRMs, 373/531 (70.2%) underwent MWA and 158/531 (29.8%) RFA. MWA demonstrated superior TRIFECTA achievement (314/373 [84.2%]) compared to RFA (114/158 [72.2%], P = 0.001). These differences were driven by higher rates of complete ablation in MWA- vs RFA-treated patients (348/373 [93.3%] vs 137/158 [86.7%], P < 0.001). In multivariable logistic regression models, MWA was associated with higher TRIFECTA achievement, compared to RFA, before (odds ratio [OR] 1.92, P = 0.008) and after PSM (OR 1.99, P = 0.023). Finally, the median OT was shorter for MWA vs RFA (105 vs 115 min; P = 0.002). At Poisson regression analyses, MWA predicted shorter OT before (incidence rate ratio [IRR] 0.86, P < 0.001) and after PSM (IRR 0.85, P < 0.001). Local recurrence occurred in 17/373 (4.6%) MWA-treated patients and 21/158 (13.3%) RFA-treated patients (P = 0.29) after a median (interquartile range) follow-up of 24 (8-46) months. There were no differences in the LRR in Kaplan-Meier plots before (P = 0.29) and after PSM (P = 0.42). Microwave ablation provides higher TRIFECTA achievement, and shorter OT than RFA. No significant differences were found regarding the LRR.

Diagnostic accuracy and safety of renal tumour biopsy in patients with small renal masses and its impact on treatment decisions.

To assess the safety and diagnostic accuracy of renal tumour biopsy (RTB) in patients with small renal masses (SRM) and to assess if RTB prevents overtreatment in patients with benign SRM. In a retrospective, single-centre study from Västmanland, Sweden, 195 adult patients (69 women and 126 men) with SRM ≤4 cm who had undergone RTB during 2010-2023 were included. The median age was 70 years (range 23-89). The sensitivity, specificity and predictive values of RTB were calculated using the final diagnosis as the reference standard. Treatment outcomes were recorded for a median 42-month follow-up. Complications following the biopsies were assessed according to the Clavien-Dindo system. The overall sensitivity of RTB was 95% (95% confidence interval [CI] 90% - 98%) and specificity was 100% (95% CI 95% - 100%). The positive predictive value was 100% and negative predictive value was 92%. The rate of agreement between RTB and the final diagnosis measured using kappa statistics was 0.92. Of the 195 patients, 62 underwent surgery and 48 were treated with ablation. The concordance rate between the RTB histology and final histology after surgery was 89%. Treatment was withheld in 67 of 195 patients with a benign or inconclusive RTB. No patients developed renal cell carcinoma or metastasis during follow-up. Complications occurred in two patients that were classified with Clavien-Dindo grades I and IV. Percutaneous renal tumour biopsy appears to be a safe diagnostic method that provides accurate histopathological information about small renal masses and reduces overtreatment of benign SRM.

Factors that Affect Outcome of Ultrasound-Guided Radiofrequency Ablation of Renal Masses.

The purpose of this study was to examine the factors influencing the efficacy and safety of the ultrasound-guided radiofrequency ablation of renal tumors. Between January 2010 and December 2018, 159 patients with renal tumors treated with ultrasound-guided percutaneous radiofrequency ablation at our institution were included in this study. Biopsies were performed for histopathological analysis prior to each ablation. Patients underwent computed tomography follow-ups at 3, 6, and 12 months and were subsequently observed on an annual basis. The primary efficacy rate (i.e., residual tumor), local tumor progression, morbidity and mortality, and possible outcome predictors (age, body mass index, gender, tumor size, tumor location, tumor characteristics, ablation temperature, and reported technical problems) were analyzed using binary logistic regression. At the first follow-up, 3 months after ablation, the primary efficacy rate was 79%. Two percent of the tumors showed local tumor progression during the whole follow-up. Tumor proximity to the collecting system and the final temperature in the ablation region were associated with the occurrence of residual tumor (OR = 2.85, p = 0.019 and OR = 4.23, p = 0.006, respectively). A similar trend was shown for tumors larger than 3 cm (p = 0.066). A short distance to the collecting system and the ablation temperature were significantly related to the occurrence of residual tumors after the radiofrequency ablation of small renal masses. The ultrasound guidance used in our study has a lower primary efficacy rate than the computed tomography guidance used in comparable studies.

Quadratus lumborum block for procedural and postprocedural analgesia in renal cell carcinoma percutaneous cryoablation.

This study assesses the efficacy of the quadratus lumborum block (QLB) in the management of procedural and periprocedural pain associated with small renal mass cryoablation. To the best of our knowledge, this is the first study that examines the use of QLB for pain management during percutaneous cryoablation of renal cell carcinoma (RCC). A single-center retrospective review was conducted for patients who underwent cryoablation for RCC with QLB between October 2020 and October 2021. The primary study endpoint included a total dose of procedural conscious sedation and administered, postprocedural analgesia. Technical success in cryoablation was achieved in every case. No patients required additional analgesic during or after the procedure, and no complications resulted from the use of the QLB. The QLB procedure appears to be an effective locoregional block for the management of procedural and periprocedural pain associated with renal mass cryoablation.

Study of complications in partial nephrectomies in 1 year period at tertiary care cancer hospital

Background: Incidental diagnosis of small renal masses are increasing now a days due to increased use of imaging by ultrasound or cross sectional investigations done for other reason or routine screening. This has led to evolution in management of small renal masses and changes in treatment modalities directed towards nephron sparing procedures. Partial nephrectomy has evolved from open, laparoscopic to Robotic-assisted procedures. There have been studies on laparoscopic partial nephrectomy but no studies have been done in our country and no comparison between open and laparoscopic approach. Materials and Methods: Cases who underwent partial nephrectomy from January 2021 to June 2024 were retrospectively analyzed. Altogether 46 patients underwent partial nephrectomy in open or laparoscopic surgery. The demographic data, pre-operative, per-operative and post-operative parameters were collected and tabulated. The early complications were defined as the complications that occurred during hospital stay or within 30 days of surgery. These were noted and classified according to Clavein-Dindo Classification. Data collected analyzed using SPSS 25 software. Results: We observed an overall complication rate of 49% vs 56% in laparoscopic group vs open group; In contrary, 13% vs 4.3% patients experienced high grade complications. The mortality rate was 0%. Conclusion: Laparoscopic partial nephrectomy had a steep learning curve. With maturity, the complications rates are not more than that of open surgery.

Outcomes of Laparoscopic Partial Nephrectomy for small renal masses

Background: Due to the increased use of imaging modalities in daily medical practices, more and more small renal masses are detected. For these SRMs, nephron sparing procedures are more commonly opted rather than radical nephrectomy for the sake of preservation of renal function and proven similar oncological outcomes. This surgery has evolved from open, laparoscopic to Robot-assisted approaches. This article summarizes our institutional experience of laparoscopic partial nephrectomy. Materials and Methods: Patients with small renal masses who underwent laparoscopic partial nephrectomy at B.P. Koirala Memorial Cancer Hospital from January 2023 to June 2024 were retrospectively retrieved. Altogether 23 case notes fulfilled the criteria for analysis. All the demographic, preoperative, intraoperative, postoperative data were collected form the notes and plotted. All the issues within 30 days of surgery were defined as early complications. Clavein-Dindo Classification used for analysis. SPSS 25 software was used. Results: Twenty three patients underwent partial nephrectomy with lapascopic method. All were done trans-peritoneally. Average age of patient was 50.96±12.8 years with range of 33-76. Male were 14 and 9 were females. Average hospital stay was 8 days. The majority of patients after PN recovered well. Nonetheless, 8 developed postoperative complications. GI complications were 8.7%, infections related 13%, Wound related 8.7% and others. Two patients (8.3%) were required to undergo reoperation and nephrectomy for haematuria. Conclusion: Laparoscopic partial nephrectomy is a surgery with steep learning curve. As it requires advanced laparoscopic suturing skills, complications in early period was common. After maturity the complications are as par to open PN.

Ischemia time in partial nephrectomy: to rush really matters?

Aim: The growth in the incidence of small renal masses has led the implementation of laparoscopic partial nephrectomy to become the technique of choice. However, arterial clamping and secondary renal ischemia still mean a controversial issue due to the risk of renal failure. Our objective is to evaluate the existing literature and its relationship to our experience. Methods: We performed a retrospective study of our series over six years. We analyzed different clinical, perioperative and postoperative functional outcome variables and compared the relationship between tumor complexity and the need for ischemia as well as the relation between ischemia time and renal function over a follow-up time of 6 months. For the discussion, we led a review of the literature on the subject and the paradigm shift that has taken place over the years. Results: A total of 148 patients, most of them male (68.2%) with an average age of 62.4 [standard deviation (SD) 1.7] years, had a Charlson index of 3 [interquartile range (IQR) 1-4]. The average R.E.N.A.L. score was 6 (IQR 5-8). Intraoperative complications were observed in 8.1% of the cases, most of which involved bleeding from a major artery or vein (7.4%). Postoperative complications occurred in 23.6% of the patients, the majority being classified as Clavien 2. Arterial clamping was carried out in 52.7% of the interventions, with a median ischemia time of 8 min (IQR 0-18). The average hospital stay was three days (IQR 2-5). Previous median glomerular filtration rate (GFR) was 83 mL/min/1.73 m2 (IQR 66.2-93.6). On the first postoperative day, the median GFR was 78.4 (SD 21.8), and at 6 months, it was 75.2 (SD 22). We found no statistically significant differences between having hypertension or diabetes mellitus and GFR after surgery, but we found differences in the correlation of a Charlson index ≥ 3 and deterioration of renal function, being the P values 0.01, 0.08 and 0.00 for the first postoperative day, after three and 6 months, respectively. No statistically significant differences were found in whether having a previous chronic kidney disease influenced the decision to perform arterial clamping or not, with a P value of 0.104. Statistically significant differences were found in the relationship between R.E.N.A.L. score and ischemia time. Conclusion: Renal tumors with a higher R.E.N.A.L. score involve the need to accomplish a longer arterial clamping, but its relationship with the deterioration of renal function is unclear, since there are other risk factors, such as patient’s comorbidities.