Treatment Of Renal Masses Research Articles

On-clamp vs off-clamp robot-assisted partial nephrectomy for achieving modified trifecta: inverse probability of treatment weighting analysis from a high-volume tertiary robotic center.

On-clamp partial nephrectomy for the surgical treatment of renal masses poses the risk of ischemia and greater post-operative renal function loss. Conversely, the off-clamp technique might enhance renal function preservation by avoiding any ischemia time. Nevertheless, the debate persists regarding the efficacy of the on- versus off-clamp partial nephrectomy in achieving better surgical, functional, and oncological outcomes. We retrospectively assessed the data from patients undergoing Robot-Assisted Partial Nephrectomy (RAPN) from 2016 and 2023 in a tertiary robotic center. Inverse probability of treatment weighting (IPTW) was used to account for selection bias in treatment allocation. The main objective of the study was assessing the achievement rates of a modified trifecta within the two groups. Multivariable logistic regression analysis (MLRA) was employed to assess the predictors of trifecta achievement. 532 patients were included in the analysis, of whom 74.1% vs. 25.9% underwent on- and off-clamp, respectively. Balancing the two groups for the main predictors of on-clamp surgery, there were no significant differences between on- and off-clamp in terms of estimated blood loss, transfusion rate, intra- and post-operative complications, positive surgical margins, and post-operative mean reduction of eGFR. Finally, no differences were found in the rate of "trifecta" achievement between on-clamp and off-clamp RAPN (24.6% vs. 21%, p = 0.82). At MLRA, off-clamp technique was not a predictor of trifecta achievement compared to the on-clamp technique (off-clamp vs. on-clamp, aOR 1.24, 95% CIs [0.65-2.36], p = 0.58). Our study revealed that clamping technique does not imply clinically relevant differences in reaching trifecta outcomes.

Percutaneous Ablation of T1 Renal Masses: Comparative Local Control and Complications after Radiofrequency and Cryoablation.

The efficacy and complication rates of percutaneous radiofrequency ablation (RFA) and cryoablation (CA) in the treatment of T1 renal masses in two Northern Italy hospitals were retrospectively investigated. Eighty-two patients with 80 T1a tumors and 10 T1b tumors treated with thermal ablation from 2015 through 2020 were included. A total of 43 tumors in 38 patients were treated with RFA (2.3 ± 0.9 cm), and 47 tumors in 44 patients were treated with CA (2.1 ± 0.8 cm). The mean follow-up observation period was 26 ± 19 months. The major complications and efficacy, as measured using the technical success and local tumor recurrence rates, were recorded. There were three (6.9%) technical failures with RFA and one (2.1%) with cryoablation (p = 0.30). Among the 40 tumors that were successfully treated with RFA, 1 tumor (2.5%) developed local tumor recurrence; 5/46 tumors that were treated with cryoablation (10.8%) developed local tumor recurrence (p = 0.17). T1b lesions (4.0 ± 0.7 cm) resulted in 1/6 technically unsuccessful cases with RFA and 0/4 with CA. No recurrent disease was detected in the T1b lesions. Major complications occurred after 2.3% (1/43) of RFAs and 0/47 of cryoablation procedures. RFA and cryoablation are both effective in the treatment of renal masses. Major complications with either procedure are uncommon.

Abstract No. 85 Comparison of Percutaneous Cryoablation and Microwave Ablation for Treatment of Renal Masses

Abstract No. 85 Comparison of Percutaneous Cryoablation and Microwave Ablation for Treatment of Renal Masses

Recommendations and optimal approaches to robotic-assisted partial nephrectomy: A consensus of Brazilian experts

ObjectiveRobotic-assisted partial nephrectomy (RAPN) is established as the gold standard approach to treating small renal masses. However, numerous technical challenges and concepts related to this approach are still under discussion and are not consensus among surgeons from different centers. We performed an online questionnaire with multiple topics about RAPN and selected high-volume surgeons from referral centers in Brazil to achieve a consensus.MethodsWe implemented an online consensus of 29 experts selected based on surgical expertise and competence in analyzing the published literature. Based on the collected literature and current Guidelines (NCCN, AUA, and EAU) we created a questionnaire with 131 questions and administered it to all participants. The statements and the Delphi technique design were combined in a single round of questions. The answers were reviewed, 70% of concordance was considered a consensus, and a final manuscript with recommendations was developed.ResultsWe divided our results into 25 subtopics that included all questions and discussions of the questionnaire, including preoperative settings, surgical technique, pathological analysis, technology use, and challenging cases. Some areas had limited data in the literature, and these potential limitations were addressed and discussed on each topic.ConclusionRAPN is the standard surgical treatment for renal masses in the centers of robotic surgery. Among the important topics of this study, we recommend always performing the first RAPN cases with proctors’ assistance, conducting preoperative planning using good-quality imaging exams, minimizing the amount of renal parenchyma removed, and achieving appropriate hemostatic suture while reducing renal parenchyma ischemia.

The Effect of Digital Three-Dimensional Reality Models on Patient Counseling for Renal Masses.

Patient counseling for treatment of renal masses is complex. It can be difficult for patients to understand their disease and make treatment decisions when being shown standard black-and-white, two-dimensional computed tomography scans or magnetic resonance images. In a telehealth setting, the patient-physician interaction can be even more challenging. We sought to determine the impact of using digital three-dimensional (3D) models during consultation visits for patients with renal masses. Forty-seven patients participating in a consultation visit for renal masses, both in-person and virtual, were shown a digital 3D model comprised of their kidney, renal mass, and key adjacent structures as part of their counseling. Patients then completed a five-question survey to assess the impact of the 3D model on their visit, with a sixth question administered to telehealth patients. Thirty-five patients undergoing telehealth visits and 12 patients seen in-person were shown the digital 3D model and surveyed. Survey results were universally positive, with all Likert scores > 4.7 (1 - 5 scale). There were no differences between the telehealth and in-person groups. Patients noted the digital 3D model made telehealth visits as effective as in-person visits (average Likert score 4.94). Counseling for patients with renal masses can be augmented with patient-specific digital 3D models, leading to increased provider loyalty, lower levels of patient anxiety, and better understanding and shared decision making.

Outcomes of cryoablation for small renal masses: a single-institution study

Background: The current study reports the clinical outcomes of the efficacy of computerized tomography (CT) guided cryoablation (CA) in the treatment of patients with small renal masses.Methods: This retrospective single institution study analyses the clinical outcomes of 36 renal tumours that were managed with cryoablation. Patient age, sex, tumour size, complications and recurrences were recorded. These patients were followed up at 3,6- and 12-months interval, they underwent biopsy and abdominal contrast enhanced ultrasound (CEUS) depending upon indications.Results: 36 patients (63.9% male, 19.4% female) each with a single small renal mass had CA with a follow-up at 3, 6 and 12 months. The mean tumour size was 606.9±31.8 mm2. Eleven complications occurred in 36 patients, for an overall complication rate of 30.6%. One (2.7%) patient had enhancement at the surgical bed on initial imaging and were considered incomplete ablations. None of the patients showed signs of distant metastases at the 3, 6 and 12-month follow-ups.Conclusions: Cryoablation of renal masses results in acceptable oncologic efficacy with an acceptable number of complications. Therefore, it remains a viable treatment for renal masses.

Robot-assisted laparoscopic partial nephrectomy: Contemporary results over a wide range of tumor complexity

Abstract Background Partial nephrectomy (PN) is considered the gold standard surgical treatment for renal masses < 7cm in size (T1 tumors). Since the introduction of the robotic-assisted laparoscopic PN (raPN) in high-volume centers, it has been increasingly adapted and standardized by urologists worldwide. There is growing evidence that the robot-assisted laparoscopic technique is associated with superior outcomes compared to those of open and conventional laparoscopic techniques. This study aimed to summarize the contemporary outcome data of raPN for renal tumors with varying degrees of complexity and to assess whether the outcomes reported from high-volume centers are reproducible in a limited caseload setting. Materials and methods This was a retrospective study of a single surgeon's experience, including 123 consecutive patients undergoing raPN at our institution. Ultimately, 110 patients were included in the analysis. Basic characteristics, tumor complexity as described by the RENAL score, complications described by the Clavien-Dindo classification system, and functional and oncological outcomes were assessed and analyzed statistically. Results Of the 110 patients, 27 (24%), 61 (55%), and 23 (21%) had low, intermediate, and high degrees of complexity, respectively, according to the RENAL score. A cancer-negative surgical margin was achieved in 108 (97%) patients. A total of 70 (64%) patients had no loss of renal function, while 20 (27%) had minimal loss of renal function. Complications of > 3 Clavien-Dindo classification during the first 30 postoperative days occurred in 5 (5%) patients. The 3 complexity groups were found to have significantly different ischemia time: Low, 8 minutes (interquartile range [IQR], 8–9.5); Intermediate, 12 minutes (IQR, 10–13); and High, 15.5 minutes (IQR, 11.25–18.75) (p < 0.001). There were no significant differences between the groups. Conclusions Contemporary standards for raPN are safe and reproducible. Adherence to the technique reported by centers of excellence yielded comparable results with regard to tumor control, preservation of renal function, and complication rates in lower-volume settings.

Prostate cancer and ethnicity, personalised treatment for renal masses and oral testosterone for hypogonadism.

Prostate cancer and ethnicity, personalised treatment for renal masses and oral testosterone for hypogonadism.

SC307 - Socioeconomic disparities in the treatment of renal masses: insight from a public referral institution

SC307 - Socioeconomic disparities in the treatment of renal masses: insight from a public referral institution

A Radiomic-based Machine Learning Algorithm to Reliably Differentiate Benign Renal Masses from Renal Cell Carcinoma

BackgroundA substantial proportion of patients undergo treatment for renal masses where active surveillance or observation may be more appropriate. ObjectiveTo determine whether radiomic-based machine learning platforms can distinguish benign from malignant renal masses. Design, setting, and participantsA prospectively maintained single-institutional renal mass registry was queried to identify patients with a computed tomography–proven clinically localized renal mass who underwent partial or radical nephrectomy. InterventionRadiomic analysis of preoperative scans was performed. Clinical and radiomic variables of importance were identified through decision tree analysis, which were incorporated into Random Forest and REAL Adaboost predictive models. Outcome measurements and statistical analysisThe primary outcome was the degree of congruity between the virtual diagnosis and final pathology. Subanalyses were performed for small renal masses and patients who had percutaneous renal mass biopsies as part of their workup. Receiver operating characteristic curves were used to evaluate each model’s discriminatory function. Results and limitationsA total of 684 patients met the selection criteria. Of them, 76% had renal cell carcinoma; 57% had small renal masses, of which 73% were malignant. Predictive modeling differentiated benign pathology from malignant with an area under the curve (AUC) of 0.84 (95% confidence interval [CI] 0.79–0.9). In small renal masses, radiomic analysis yielded a discriminatory AUC of 0.77 (95% CI 0.69–0.85). When negative and nondiagnostic biopsies were supplemented with radiomic analysis, accuracy increased from 83.3% to 93.4%. ConclusionsRadiomic-based predictive modeling may distinguish benign from malignant renal masses. Clinical factors did not substantially improve the diagnostic accuracy of predictive models. Enhanced diagnostic predictability may improve patient selection before surgery and increase the utilization of active surveillance protocols. Patient summaryNot all kidney tumors are cancerous, and some can be watched. We evaluated a new method that uses radiographic features invisible to the naked eye to distinguish benign masses from true cancers and found that it can do so with acceptable accuracy.

Nephron sparing surgery for the treatment of renal masses: A single center experience.

Nowadays, the partial nephrectomy (PN) not only is considered oncological equivalent to radical nephrectomy as renal tumor's treatment, but has also give benefits in quality of life and overall survival of patients. The primary objective of the present study was to report our single center experience with NSS, predominantly performed by a robot assisted access, in a high-volume center with large experience with minimally invasive surgery. Between June 2018 and January 2020, a consecutive series of 109 patients (pts) with a renal mass suspicious of renal cell carcinoma, feasible of NSS, detected by ultrasound and abdominal computed tomography (CT), underwent NSS and they were included in a prospectively maintained institutional database. Baseline demographics and clinical characteristics, perioperative and postoperative parameters, pathological data were recorded. The mean clinical maximum CT tumor diameter was 37.3 ± 19.6 mm (median 31.5 mm; interquartile range 25-45 mm). PADUA risk was low in 54 pts (49.5%), intermediate in 48 pts (44.0%), high in seven pts (6.4%). The clinical T stage was mostly pT1a (70.6%). NSS was performed by open surgery in nine pts (8.3%), laparoscopy in one pts (0.9%) and was robot assisted in 99 pts (90.8%). A simple enucleation was performed in 67 pts (61.5%), an enucleoresection was performed in 37 pts (33.9%) and a partial nephrectomy was performed in five pts (4.6%). Warm ischemia was performed in 41 pts (37.6%), with a mean warm ischemia time of 5.1 ± 7.1 min. The mean pathological maximum tumor diameter was 35.5 ± 21.7 mm (median 30 mm; interquartile range 22-40 mm). Overall PSM rate was 11.9% (13 pts). In 78% of cases no complication was recorded. No major complications (grade III-IV-V) were noted. Our findings suggest that NSS is a safe, reproducible and minimally invasive approach as treatment of small renal masses. NSS permits to achieve a fine oncological management without any worsening of renal function.

Fully perfused laparoscopic partial nephrectomy: surgical technique and outcomes

Objective: To present a surgical technique and outcome of fully perfused laparoscopic partial nephrectomy (LPN). Material and Method: Fifteen patients underwent fully perfused LPN between January 2014 and January 2018 for renal masses. We studied a subgroup of patients who underwent fully perfused LPN (non-clamp). Our technique was utilized for exophytic, non-hilar masses that had a diameter of less than 2 cm. We developed our technique to avoid ischemia reperfusion renal injury while minimizing bleeding. Results: We reviewed 15 cases of fully perfused LPN. Utilizing a non-clamp procedure resulted in an average blood loss of 100 ml, 2 days of hospital stay, and minimal change in serum creatinine. Conclusion: Fully perfused LPN is a feasible procedure for the treatment of renal masses. Benefits of this procedure are its minimal invasiveness and prevention of ischemic reperfusion kidney injury.

'Trifecta' outcomes of robot-assisted partial nephrectomy: Results of the 'low volume' surgeon.

ABSTRACTObjective There is limited data regarding surgeon volume and partial nephrectomy outcomes. The aim of this study is to report trifecta outcomes of robot-assisted partial nephrectomy (RAPN) performed by the low volume surgeon.Materials and Methods Thirty-nine patients with clinical T1-2 renal tumors who underwent RAPN between 2012 and 2018 were included in this study. Trifecta was defined as negative surgical margins, warm ischemia time ≤20 minutes, and no operative complications. Patient demographics, R.E.N.A.L. nephrometry score, operation time, estimated blood loss, warm ischemia time, length of hospital stay, renal functions, and oncological outcomes were analyzed retrospectively. Complications were graded based on the modified Clavien-Dindo classification system.Results The median R.E.N.A.L. nephrometry score was 6 (4-10). RAPN was successfully performed in all but one patient. The median operation time was 180 (90-240) minutes. Warm ischemia was performed only by segmental renal artery control in 35 and, by main renal artery control in three patients. The off-clamp technique was used in two patients. The median warm ischemia time was 16 (0-31) minutes. Seven patients had a warm ischemia time of longer than 20 minutes. Three patients had postoperative complications. The surgical margin was positive in one patient. As a result, the trifecta was achieved in 30 of the 39 patients (77%).Conclusion RAPN is a safe and effective minimally invasive alternative in the treatment of renal masses. The present study suggests that reasonable trifecta rates can be achieved even by low volume surgeons.

Computed tomography (CT)-guided percutaneous coaxial biopsy combined with microwave ablation for the treatment of renal masses

Purpose This study aimed to investigate the feasibility, safety, and efficacy of computed tomography (CT)-guided percutaneous coaxial biopsy combined with microwave ablation (MWA) for the treatment of renal masses. Material and methods The clinical data of ten patients (14 tumors) treated with CT-guided percutaneous coaxial biopsy combined with MWA from January 2017 to November 2019 were retrospectively analyzed. The patients were followed up for 2–33 months. The outcomes were evaluated with plain and contrast spiral CT scans. Renal function was assessed using the estimated glomerular filtration rate. Results No severe MWA-related complication was observed. All the tumors were successfully ablated. There was no imaging evidence of local residual tumor, local tumor recurrence, or disease progression during the follow-up period. Conclusions CT-guided percutaneous coaxial biopsy combined with MWA might be an effective option for the diagnosis and treatment of renal masses in selected patients.

Intermediate to Long-Term Clinical Outcomes of Percutaneous Cryoablation for Renal Masses

PurposeThe purpose of this study was to evaluate the effectiveness and adverse outcomes of percutaneous cryoablation (CA) for treatment of renal masses in a large cohort of patients. Materials and MethodsThis retrospective analysis included 299 CA procedures (297 masses in 277 patients) performed between July 2007 and May 2018 at a single institution. The mean patient age was 66.1 years (range, 30–93 years) with 65.8% being male. A total of 234 (78.8%) masses were biopsy-proven renal cell carcinoma (RCC). The mean maximal tumor diameter was 2.5 cm (range, 0.7–6.6 cm). Efficacy was assessed only for ablations of biopsy-proven RCC, whereas the evaluation of adverse events and renal function included all masses. Complications were graded according to the Society of International Radiology classification. ResultsMajor complications occurred in 3.0% of procedures (n = 9), none of which resulted in death or permanent disability. The mean imaging follow-up period was 27.4 months (range, 1–115) for the 199 RCC patients (204 ablated tumors) with follow-up imaging available. Complete response on initial follow-up imaging at mean 4.2 months (range, 0.3–75.6) was achieved in 195 of 204 tumors (95.6%) after a single session and in 200 of 204 tumors (98.0%) after 1 or 2 sessions. Of the RCC patients achieving complete response initially, local recurrence during the follow-up period occurred in 3 of 200 tumors (1.5%). Metastatic progression occurred in 10 of 193 (5.2%) RCC patients without prior metastatic disease during follow-up. ConclusionsCA for renal masses is safe and remains efficacious through intermediate- and long-term follow-up.

Role of 3D printing in surgical education for robotic urology procedures.

During the past 5 years, the body of literature surrounding the utilization of three-dimensional (3D) printing in the field of urology has grown exponentially. Incentivized by work hour restrictions, patient safety initiatives, and inspired by technical advances in biomaterials and rapid printing strategies, this emerging, and fascinating area of research has begun to make headway into clinical practice. However, concerns about cost, limited understanding of the technical processes involved, and lack of its potential uses remain barriers to its widespread adoption. We examined existing published literature on how 3D printing technologies have been utilized in the field of Urology to enhance pre-operative planning, revitalize surgical training, and modernize patient education, with particular focus on, robotic surgery. To date, 3D-printed models have been used and studied most commonly in the preoperative planning for nephron-sparing surgeries during the treatment of renal masses, where the challenges of complex renal anatomy and benefits of reducing renal ischemic injury create the most intuitive value. Prostate models are the second most common, particularly in the planning of nerve-sparing procedures. Early studies have demonstrated sufficient realism and educational effectiveness. Subsequent studies demonstrated improved surgeon confidence, operative performance, and optimized patient outcomes including high levels of patient satisfaction. Realistic, accurate, and reasonably priced models can currently be generated within hours using standard desktop 3D printers. While primarily utilized as anatomic replicas of diseased organs that restore a sense of haptic feedback lost in robotic procedures, innovations in polymers, improvements in 3D printer host and modeling software, and upgrades in printer hardware allow this technology to serve as a comprehensive, interactive, simulation platform that can be a critical surgical decision making as well as an effective teaching tool. As Urologists continue to rapidly diversify and iterate upon this adaptive modality, the benefits in patient outcomes will likely outpace the diminishing drawbacks, and we may well see the next revolution in surgical education, robotic techniques, and personalized medicine concurrently.

Nephrometry Scoring System Selects Candidates for Radical Nephrectomy versus Nephron-Sparing Surgery for Treatment of Renal Masses and Predicts Surgical and Oncological Outcome

Purpose: The study was designed to ensure the sensitivity of preoperative planning by applying radius, endophytic/exophytic, nearness to collecting system, anterior/posterior, and location to poles (RENAL) nephrometry scoring system on computed tomography films of patients having organ-confined solid and cystic renal tumors and to assess its correlation with the surgical technique by applying RENAL on the specimen intraoperative. Materials and Methods: Eighty-five patients with organ-confined solid and cystic renal masses underwent RENAL nephrometry system which was correlated with the surgical technique either radical or nephron-sparing surgery or the surgical and oncological outcome. Results: RENAL nephrometry scoring system shows high sensitivity with the type and outcome of surgery of resection of the renal tumors. Conclusion: RENAL nephrometry score system is an objective method to help in the decision of surgical approach to resect organ-confined solid and cystic renal tumors.

Nephrometry scoring system selects candidates for radical nephrectomy versus nephron sparing surgery for treatment of renal masses and predicts surgical and oncological outcome

Nephrometry scoring system selects candidates for radical nephrectomy versus nephron sparing surgery for treatment of renal masses and predicts surgical and oncological outcome

Non-neoplastic pathologic findings in nephrectomy specimens; postoperative renal insufficiency and outcomes

Introduction: Incidence of renal masses has increased with increased abdominal imagings. The trend in treatment of renal masses has been toward renal preserving options, including surveillance, ablation and partial nephrectomy. Objectives: To determine the frequency of medical renal disease in patients undergoing surgical intervention for renal neoplasms and to establish whether these pathologic changes predict development of renal insufficiency in the immediate postoperative period. Patients and Methods: This was an Institutional Review Board (IRB)-approved retrospective review of all patients that underwent radical nephrectomy (RN), partial nephrectomy and nephroureterectomy from December 2009 to November 2013. Around 225 patients had complete pathologic and perioperative data for analysis. We compared preoperative and postoperative glomerular filtration rate (GFR), neoplastic findings, tumor characteristics (positive margins and extracapsular extension), and pathology information regarding non- neoplastic findings (tubular atrophy, chronic inflammation and fibrosis). Results: The presence of any pathologic abnormalities in the non-neoplastic renal parenchyma was significantly associated with increased serum creatinine levels postoperatively (P=0.01) and at last follow up visit (P=0.04). Univariate analysis showed that glomerular and vascular abnormalities were each significantly associated with worsening renal function. Conclusion: Our research suggests that abnormalities in non-neoplastic renal parenchyma found in renal specimens after RN should not be ignored as they may predict possible worse outcomes in renal function. This may help make a case for biopsy pre-operatively and a stronger case for nephron sparing surgery. This may also help determine which patients should be followed more closely postoperatively.

SC88 - A case series of neoplastic seeding after cryoablative treatment for renal masses

SC88 - A case series of neoplastic seeding after cryoablative treatment for renal masses