Current Management of Urachal Carcinoma: An Evidence-based Guide for Clinical Practice

Unlabelled: Urachal carcinoma is a rare urological disease. The shortage of data about diagnosis and surgical treatment in literature makes it hard for clinicians to make a decision. Indeed, urachal carcinoma is an aggressive disease that requires prompt staging and treatment to ensure the best outcome for patients. We reviewed the last evidence about the management of urachal carcinoma to provide an easy-to-use guide for clinical practice. Patient summary: Urachal carcinoma is a rare malignancy. The literature on this challenging disease remains limited. Herein, we provide a practical guide for its management from diagnosis to treatment, which in most cases requires surgical intervention or chemotherapy

Robotic partial nephrectomy for large renal Leiomyoma: first case report

ABSTRACT Aim: Renal leiomyoma is a rare benign mesenchymal tumor arising from the smooth muscle cells of the kidney. Renal capsule is its most common location (1). Large tumor may require surgical excision which can be challenging in case of proximity to major vessels (2). Indications of robotic partial nephrectomy (RPN) have exponentially expanded over the past few years (3). We aim to report a case of large renal leiomyoma successfully managed with RPN. Methods: A 59-year-old female patient with BMI 51 presented with chief complaint of abdominal discomfort. The patient underwent a CT scan that revealed a massive circumscribed exophytic complex solid cystic mass of 4.5 × 7.7 × 6.2 cm, arising from the lower pole of right kidney and abutting the inferior vena cava. RENAL score was 11ah (high complexity). Past surgical history included mid-urethral sling, breast reduction, and hysterectomy with salpingectomy. Preoperative creatinine and eGFR were 0.9 (mg/dL) and 77 (mL/min), respectively. A robotic excision of this mass was successfully performed by using Da Vinci Xi platform. Main steps of the procedure are illustrated in the present video. Results: Dissection and isolation of the tumor were carefully performed after identifying key anatomical structures such as the ureter, the IVC and the renal hilum. Intraoperative ultrasound was used to confirm the margins of the mass. The renal artery was clamped and then the tumor was resected/enucleated. Renal parenchyma was re-approximated with a single layer of interrupted CT-1 Vicryl 0 with sliding clip technique. Warm ischemia time was 19 min. Estimated blood loss (EBL) was 250 ml. Operative time was 165 min. No intraoperative complications occurred. No drain was placed. Patient was discharged on postoperative day 2. Post-operative hypotension was managed with fluid bolus. Postoperative creatinine and eGFR were 1,0 (mg/dL) and 69 (mL/min/1.72m2), respectively. Pathology revealed a leiomyoma of genital stromal origin with hyalinization and calcification. Conclusions: To the best of our knowledge, this is the first description of RPN for the management of a large (about 8 cm) renal leiomyoma. Robotic assisted surgery allows to expand the indications of minimally invasive conservative renal surgery whose feasibility becomes even more clinically significant in case of benign masses which can be managed without sacrificing healthy renal parenchyma

Microwave versus cryoablation and radiofrequency ablation for small renal mass: a multicenter comparative analysis

Background: Ablative techniques emerged as effective alternative to nephron-sparing surgery for treatment of small renal masses. Radiofrequency ablation (RFA) and cryoablation (CRYO) are the two guidelines-recommended techniques. Microwave ablation (MWA) represents a newer technology, less described. The aim of the study was to compare outcomes of MWA to those of CRYO and RFA. Methods: Retrospective investigation of patients who underwent MWA, CRYO, or RFA from seven high-volume US and European centers was performed. The first group included patients who underwent CRYO or RFA; the second MWA. We collected baseline characteristics, clinical, intraoperative, and postoperative data. Oncological data included technical success, local recurrence, and progression to metastasis. Multivariate analysis was performed to find predictors for postoperative complications. A composite outcome of "trifecta" was used to assess surgical, functional, and oncological outcomes. Results: 739 patients underwent CRYO or RFA and 50 MWA. CRYO/RFA group had significantly longer operative time (P<0.001), but no difference in LOS, postprocedural Hb mean, intraprocedural complications (P=0.180), overall postprocedural complication rates (P=0.126), and in the 30-day re-admission rate (P=0.853) were detected. No predictive parameter of postprocedural complications was found. Concerning functional outcome, no differences were detected in terms of eGFR at 1 year (P=0.182), ΔeGFR at 1 year (P=0.825) and eGFR at latest follow-up (P=0.070). "Technical success" was achieved in 98.6% of the cases (MWA=100%, CRYO/RFA=98.5%; P=0.775), and there was no significant difference in terms of 2-year recurrence rate (P=0.114) and metastatic progression (P=0.203). Trifecta was achieved in 73.0% of CRYO/RFA vs. 69.6% of MWA cases (P=0.719). Conclusions: MWA is a safe and effective treatment option for small renal masses. Compared with CRYO/RFA, it seems to offer low complication rates, shorter operation time, and equivalent surgical and functional outcomes

Management of the incidental adrenal mass, continued surveillance versus surgical excision: analysis of US claims data on contemporary socio-demographic predictors and perioperative outcomes

Background: Incidentally diagnosed adrenal masses represent an entity that can result in either long term follow-up, surgical excision, or both. Understanding when and which adrenal masses are ultimately excised surgically is not well understood. We sought to understand the ultimate fate of these incidentalomas using a large population-based dataset. Methods: The primary outcome of the study was determining the trend in adoption of surveillance vs. surgical excision according to socio-demographic, economic, and pathologic indices, and also provider specialty. Secondary outcomes were the assessment of perioperative complications, operative time, surgical approach, hospital stay, and provider specialty (general surgery vs. urology) among the cohort that underwent excision. Results: Out of a total of N.=91,560 adrenal masses, ultimately N.=3375 (3.83%) of these underwent surgical excision. In the surgical excision cohort, the incidence of aldosteronoma, functional adenoma/Cushing's disease, and adrenocortical carcinoma was higher than in the surveillance cohort. Those patients who were older, female, and with higher Charlson Comorbidity indexes (CCI) were less likely to undergo surgical resection. Factors that predicted for an increased probability of resection included obtaining more CT/MRI scans as well as general surgeons as primary physician providers. Over the study period, the vast majority of surgeries were performed by surgeons other than urologists (12.9%) and open and laparoscopic approaches dominated, with the robotic-assisted approach accounting for a minority of the surgical cases (23.9%). The minimally invasive surgery (MIS) approach independently predicted for both lower rates of complications and shorter hospital stay. Conclusions: In the US, adrenal incidentalomas are more likely to undergo surveillance rather than surgical resection. In our study, surgery is mainly offered for functional or malignant disease and the receipt of surgery can vary by physician specialty. A MIS approach independently predicted for both lower rates of complications and shorter hospital stay

Partial versus radical nephrectomy for complex renal mass: multicenter comparative analysis of functional outcomes (Rosula collaborative group)

Background: Utility of partial nephrectomy (PN) for complex renal mass (CRM) is controversial. We determined the impact of surgical modality on postoperative renal functional outcomes for CRM. Methods: We retrospectively analyzed a multicenter registry (ROSULA). CRM was defined as RENAL Score 10-12. The cohort was divided into PN and radical nephrectomy (RN) for analyses. Primary outcome was development of de-novo estimated glomerular filtration rate (eGFR)&lt;45 mL/min/1.73 m2. Secondary outcomes were de-novo eGFR&lt;60 and ΔeGFR between diagnosis and last follow-up. Cox proportional hazards was used to elucidate predictors for de-novo eGFR&lt;60 and &lt;45. Linear regression was utilized to analyze ΔeGFR. Kaplan-Meier Analysis (KMA) was performed to analyze 5-year freedom from de-novo eGFR&lt;60 and &lt;45. Results: We analyzed 969 patients (RN=429/PN=540; median follow-up 24.0 months). RN patients had lower BMI (P&lt;0.001) and larger tumor size (P&lt;0.001). Overall postoperative complication rate was higher for PN (P&lt;0.001), but there was no difference in major complications (Clavien III-IV; P=0.702). MVA demonstrated age (HR=1.05, P&lt;0.001), tumor-size (HR=1.05, P=0.046), RN (HR=2.57, P&lt;0.001), and BMI (HR=1.04, P=0.001) to be associated with risk for de-novo eGFR&lt;60 mL/min/1.73 m2. Age (HR=1.03, P&lt;0.001), BMI (HR=1.06, P&lt;0.001), baseline eGFR (HR=0.99, P=0.002), tumor size (HR=1.07, P=0.007) and RN (HR=2.39, P&lt;0.001) were risk factors for de-novo eGFR&lt;45 mL/min/1.73 m2. RN (B=-10.89, P&lt;0.001) was associated with greater ΔeGFR. KMA revealed worse 5-year freedom from de-novo eGFR&lt;60 (71% vs. 33%, P&lt;0.001) and de-novo eGFR&lt;45 (79% vs. 65%, P&lt;0.001) for RN. Conclusions: PN provides functional benefit in selected patients with CRM without significant increase in major complications compared to RN, and should be considered when technically feasible

Partial versus radical nephrectomy for complex renal mass: multicenter comparative analysis of functional outcomes (Rosula collaborative group).

BACKGROUND: Utility of partial nephrectomy (PN) for complex renal mass (CRM) is controversial. We determined the impact of surgical modality on postoperative renal functional outcomes for CRM. METHODS: We retrospectively analyzed a multicenter registry (ROSULA). CRM was defined as RENAL Score 10-12. The cohort was divided into PN and radical nephrectomy (RN) for analyses. Primary outcome was development of de-novo estimated glomerular filtration rate (eGFR)/min/1.73 m RESULTS: We analyzed 969 patients (RN=429/PN=540; median follow-up 24.0 months). RN patients had lower BMI (P CONCLUSIONS: PN provides functional benefit in selected patients with CRM without significant increase in major complications compared to RN, and should be considered when technically feasible

Partial or radical nephrectomy for complex renal mass: a comparative analysis of oncological outcomes and complications from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group.

Purpose: To compare outcomes of robotic-assisted partial nephrectomy (RAPN) and minimally invasive radical nephrectomy (MIS-RN) for complex renal masses (CRM). Methods: We conducted a retrospective multicenter analysis of CRM patients who underwent MIS-RN and RAPN. CRM was defined as RENAL score 10-12. Primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS), recurrence, and complications. Multivariable analysis (MVA) and Kaplan-Meier Analysis (KMA) were used to analyze functional and survival outcomes for RN vs. PN by pathological stage. Results: 926 patients were analyzed (MIS-RN = 437/RAPN = 489; median follow-up 24.0 months). MVA demonstrated lack of transfusion (HR = 1.63, p = 0.005), low-grade (HR = 1.18, p = 0.018) and smaller tumor size (HR = 1.05, p \u3c 0.001) were associated with OS. Younger age (HR = 1.01, p = 0.017), high-grade (HR = 1.18, p = 0.017), smaller tumor size (HR = 1.05, p \u3c 0.001), and lack of transfusion (HR = 1.39, p = 0.038) were associated with CSS. Increasing tumor size (HR = 1.18, p \u3c 0.001), high-grade (HR = 3.21, p \u3c 0.001), and increasing age (HR = 1.02, p = 0.009) were independent risk factors for recurrence. Type of surgery was not associated with major complications (p = 0.094). For KMA of MIS-RN vs. RAPN for pT1, pT2 and pT3, 5-year OS was 85% vs. 88% (p = 0.078); 82% vs. 80% (p = 0.442) and 84% vs. 83% (p = 0.863), respectively. 5-year CSS was 98% for both procedures (p = 0.473); 94% vs. 92% (p = 0.735) and 91% vs. 90% (p = 0.581). 5-year non-CSS was 87% vs. 93% (p = 0.107); 87% for pT2 (p = 0.485) and 92% for pT3 for both procedures (p = 0.403). Conclusion: RAPN in CRM is not associated with increased risk of complications or worsened oncological outcomes when compared to MIS-RN and may be preferred when clinically indicated

Prognostic Significance of Grade Discrepancy Between Primary Tumor and Venous Thrombus in Nonmetastatic Clear-cell Renal Cell Carcinoma: Analysis of the REMEMBER Registry and Implications for Adjuvant Therapy

Background: Further stratification of the risk of recurrence of clear-cell renal cell carcinoma (ccRCC) with venous tumor thrombus (VTT) will facilitate selection of candidates for adjuvant therapy. Objective: To assess the impact of tumor grade discrepancy (GD) between the primary tumor (PT) and VTT in nonmetastatic ccRCC on disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS). Design, setting, and participants: This was a retrospective analysis of a multi-institutional nationwide data set for patients with pT3N0M0 ccRCC who underwent radical nephrectomy and thrombectomy. Outcomes measurements and statistical analysis: Pathology slides were centrally reviewed. GD, a bidirectional variable (upgrading or downgrading), was numerically defined as the VTT grade minus the PT grade. Multivariable models were built to predict DFS, OS, and CSS. Results and limitations: We analyzed data for 604 patients with median follow-up of 42 mo (excluding events). Tumor GD between VTT and PT was observed for 47% (285/604) of the patients and was an independent risk factor with incremental value in predicting the outcomes of interest (all p &lt; 0.05). Incorporation of tumor GD significantly improved the performance of the ECOG-ACRIN 2805 (ASSURE) model. A GD-based model (PT grade, GD, pT stage, PT sarcomatoid features, fat invasion, and VTT consistency) had a c index of 0.72 for DFS. The hazard ratios were 8.0 for GD&nbsp;=&nbsp;+2 (p &lt; 0.001), 1.9 for GD&nbsp;=&nbsp;+1 (p &lt; 0.001), 0.57 for GD&nbsp;=&nbsp;-1 (p&nbsp;=&nbsp;0.001), and 0.22 for GD&nbsp;=&nbsp;-2 (p&nbsp;=&nbsp;0.003) versus GD&nbsp;=&nbsp;0 as the reference. According to model-converted risk scores, DFS, OS, and CSS significantly differed between subgroups with low, intermediate, and high risk (all p &lt; 0.001). Conclusions: Routine reporting of VTT upgrading or downgrading in relation to the PT and use of our GD-based nomograms can facilitate more informed treatment decisions by tailoring strategies to an individual patient's risk of progression. Patient summary: We developed a tool to improve patient counseling and guide decision-making on other therapies in addition to surgery for patients with the clear-cell type of kidney cancer and tumor invasion of a vein