Cardiovascular surgical experiences of IVC tumor and thrombus: Operative strategies Based on 51 consecutive patients

BACKGROUND

The only beneficial treatment option for the management of inferior vena cava (IVC) tumor thrombus is complete tumor removal. The aim of this study was to report our experience in surgical and clinical outcomes in patients with tumor thrombosis in IVC.

METHODS

A retrospective chart review of patients who underwent surgical resection of IVC tumor at our institution over the past 10 years was performed. The patients were identified using a prospectively maintained database.

RESULTS

We identified 51 patients, the mean age was 53.4 ± 16.8 years, and 25.4% were female. They were divided into three groups based on tumor thrombosis level. Twenty patients (39.2%) required sternotomy, and cardiopulmonary bypass (CPB) was used in 19 (37.2%) patients, and 2 (3.9%) cases underwent coronary artery bypass graft. The perioperative complications were severe bleeding (3 patients), pulmonary embolism (2 patients), and duodenal perforation (1 patient). Three (5.8%) in-hospital deaths occurred, and all were due to severe abdominal bleeding. After a mean follow-up time of 46.5 ± 42.0 months, 29 (56.9%) patients were alive. The mean survival time was 75.2 ± 8.4 months. In multivariate analysis, higher age (p = 0.033) and male gender (p = 0.033) proved to be independent prognostic factors.

CONCLUSIONS

Tumor thrombus extending to the IVC is a rare and challenging event. Although using CPB may be safe and result in long-term survival with acceptable function, excessive bleeding during surgery may limit the use of this method.

Laparoscopic and Open Nephron-Sparing Surgery for Radius Exophytic/Endophytic Nearness Anterior/ Posterior Location Nephrometry Score 7 and Higher Kidney Tumors: A Comparison of Oncological and Functional Outcomes Using the Pentafecta Score

OBJECTIVE

This study aimed to evaluate oncological and functional outcomes of nephron- sparing surgery by comparing open and laparoscopic approaches in a consecutive series of patients with intermediate and high complexity renal masses.

MATERIALS AND METHODS

We retrospectively reviewed all nephron-sparing surgery cases in 2 referral centers from January 2013 to January 2020. Tumor complexity was graded according to radius exophytic/endophytic nearness anterior/posterior location nephrometry score. Patients with a single kidney tumor with a radius exophytic/endophytic nearness anterior/posterior location score ≥ 7 were evaluated. Exclusion criteria were solitary kidney, multiple/bilateral tumors, and a low radius exophytic/endophytic nearness Anterior/Posterior location score (<7). Patients were divided according to the surgical approach: the laparoscopic tumor enucleation and the open wedge resection groups. The Trifecta and Pentafecta score achievement rates were assessed.

RESULTS

Two hundred thirteen patients were included in the analysis, 76 in laparoscopic tumor enucleation group and 137 in the open wedge resection group. There were no statistically significant differences in preoperative data between laparoscopic tumor enucleation and open wedge resection groups, except for the higher percentage of T1a masses in the latter group. The mean 24-hour blood loss and length of stay were higher in the open wedge resection group. Minor and major postoperative complication rates were comparable. No significant difference in terms of the Trifecta score was reported. Pentafecta score was achieved in 35/76 (46.1%) and 61/137 (44.5%) cases in the laparoscopic tumor enucleation and open wedge resection groups, respectively.

CONCLUSION

Our study showed that laparoscopic tumor enucleation was associated with significantly lower blood and length of stay. Postoperative complications and the achievement of the Pentafecta score were similar in both surgical approaches.

Pediatric Primary Yolk Sac Tumour of the Kidney: Recommendations for Pretreatment Diagnosis

Introduction Although nephroblastomas are frequently treated without prior biopsy, there are the occasional other pediatric renal tumors that require different management. In the literature, there are around 30 primary renal germ cell tumors (GCT), including four cases of Yolk sac tumor (YST). We present another primary renal YST.Case report: A five-year-old boy was diagnosed as Wilms tumor on radiology and needle biopsy. He received chemotherapy, with no response. The post-chemotherapy resection specimen revealed a YST.Conclusion: Renal YST may be indistinguishable from Wilms tumor clinically and radiologically. For pre-biopsy chemotherapy management protocols, serum tumor markers such as AFP may be recommended to identify the occasional GCT, including YST. Pre-chemotherapy needle biopsies may lead to misdiagnosis, and may require confirmation by an experienced pathologist or central review.

Diagnostic Value of Multi-Mode Ultrasonic Flow Imaging Examination in Solid Renal Tumors of Different Sizes

Purposes: To explore the value of Microflow Imaging (MFI) in renal solid tumors. Methods: A total of 195 patients with 199 lesions pathologically confirmed masses were retrospectively analyzed. The 199 masses were divided into the tumor ≤ 4 cm group (n = 104) and tumor > 4 cm group (n = 95). The diagnostic efficacy of Color Doppler Flow Imaging (CDFI), Power Doppler Imaging (PDI) and MFI in renal tumors sizes were compared by determining the Adler grade, vascular morphology and peripheral blood flow. Results: Among 199 tumors, 161 lesions were malignant and 38 lesions were benign. MFI in malignant tumor ≤ 4 cm demonstrated statistically significant differences in Adler grade and vascular morphology as compared to CDFI and PDI (p < 0.05). In malignant tumor > 4 cm group, MFI showed significant difference in vascular morphology compared with CDFI (p < 0.05). MFI showed a significant difference in the peripheral annular blood flow of malignant tumors when compared to CDFI and PDI (p < 0.05). In addition, the malignant tumors of the two sizes by MFI in peripheral annular blood flow detection showed significant difference (p < 0.05). The area under the curve of ROC by MFI in the tumor ≤ 4 cm was 0.771, which was higher than CDFI and PDI (p < 0.05), but no obvious difference among the tumor > 4 cm (p > 0.05). Conclusion: MFI provides a new method for the differential diagnosis of small renal carcinoma. Based on the convenience and non-radiation of MFI, we can choose MFI as an imaging diagnostic tool for patients who need long-term active surveillance (AS) follow-up.

Cone Beam Computed Tomography Image Fusion with Cross Sectional Images for Percutaneous Renal Tumor Ablation: Preliminary Data

PURPOSE

Percutaneous ablative treatments in the kidney are now standard options for local cancer therapy. Multimodality image guidance, combining two 3D image sets, may improve procedural images and interventional strategies. We aimed to assess the value of intra-procedural cone beam computed tomography (CBCT) with magnetic resonance (MR) or CT imaging fusion technique in the guidance of percutaneous microwave ablation (MWA) of renal neoplasms.

MATERIALS AND METHODS

Fifteen patients (eight males, seven females, median age 65 years, median lesion size 20 mm) underwent percutaneous MWA for 15 renal tumors. All the procedures were performed in a dedicated angiography room setting; CBCT ablation planning capabilities included multimodality image fusion. Preoperative contrast-enhanced CT was available in 12 patients, whereas magnetic resonance imaging in the remaining. All patients were considered inoperable due to comorbidities, advanced age, and/or refusal to undergo surgery. Exclusion criteria were: tumors visible at unenhanced CBCT, metastatic disease, and uncorrected coagulopathy. Technical success and technical effectiveness were calculated. Procedural time, complications and recurrences were registered.

RESULTS

MWA under CBCT-guidance with fusion technique was technically successful in 14 out of 15 cases (93%). The median procedural time was 45 min. No procedure-related complications were reported. No enhancing tissue was visualized in the area of ablation at 1-month follow-up. All 15 cases were recurrence-free at last follow-up assessment (median follow-up of 12 months); no cancer-specific deaths were registered.

CONCLUSION

CBCT-CT/MR image fusion is technically feasible and safe in achieving correct targeting and complete ablation of renal lesions. This approach bears the potential to overcome most of the limitations of unenhanced CBCT guidance alone; larger series are needed to validate this technique.

Whole-Lesion CT Texture Analysis as a Quantitative Biomarker for the Identification of Homogeneous Renal Tumors

Renal tumors are very common in the urinary system, and the preoperative differential diagnosis of homogeneous renal tumors remains a challenge. This study aimed to evaluate the feasibility of the whole-lesion CT texture analysis for the identification of homogeneous renal tumors including clear cell renal cell carcinoma (ccRCC), chromophobe RCC (chRCC), and renal oncocytoma (RO). This retrospective study was approved by our local IRB. Contrast-enhanced CT examination was performed in 128 patients and histopathologically confirmed ccRCC, chRCC, and RO. The one-way ANOVA test with Bonferroni corrections was used to compare the differences, and the receiver operating characteristic (ROC) curve analysis was applied to determine the diagnostic efficiency. The whole-lesion CT histogram analysis was used to demonstrate significant differences between ccRCC and chRCC in both arterial and venous phases, and the entropy demonstrated excellent performance in discriminating these two types of tumors (AUCs = 0.95, 0.91). The inhomogeneity of ccRCC was significantly higher than that of RO both in arterial and venous phases. The entropy of chRCC was significantly lower than that of RO, and the kurtosis and entropy yielded high sensitivity (91%) and moderate specificity (74%) in the arterial phase. The whole-lesion CT histogram analysis could be useful for the differential diagnosis of homogeneous ccRCC, chRCC, and RO.

Renal Mass Found on Imaging of Spine for Back Pain: An Incidental Finding

A middle-aged female patient who presented with back pain was found incidentally to have a renal mass by magnetic resonance imaging (MRI). Further imaging, including computerized tomography (CT) with contrast, suggested a high likelihood of malignancy. Following surgical resection, the tumor was found to be a rare benign lesion on subsequent pathological examination. The patient had conservative treatment for her presenting spine issues and is doing very well. Prompt work-up and treatment of incidental findings by the team of primary care, physical medicine and rehabilitation physicians, radiologists, pathologists, and surgeons helped to ensure a good outcome. Residents had a learning opportunity about the disease and on timely management of incidental findings.

An Evaluation of a Web-Based Decision Aid for Treatment Planning of Small Kidney Tumors: Pilot Randomized Controlled Trial

Background

Surgery is the most common treatment for localized small kidney masses (SKMs) up to 4 cm, despite a lack of evidence for improved overall survival. Nonsurgical management options are gaining recognition, as evidence supports the indolence of most SKMs. Decision aids (DAs) have been shown to improve patient comprehension of the trade-offs of treatment options and overall decision quality, and may improve consideration of all major options according to individual health priorities and preferences.

Objective

This pilot randomized controlled trial (RCT) primarily aims to evaluate the impact of a new web-based DA on treatment decisions for patients with SKM; that is, selection of surgical versus nonsurgical treatment options. Secondary objectives include an assessment of decision-making outcomes: decisional conflict, decision satisfaction, and an understanding of individual preferences for treatment that incorporate the trade-offs associated with surgical versus nonsurgical interventions.

Methods

Three phases comprise the construction and evaluation of a new web-based DA on SKM treatment. In phase 1, this DA was developed in print format through a multidisciplinary design committee incorporating patient focus groups. Phase 2 was an observational study on patient knowledge and decision-making measures after randomization to receive the printed DA or institutional educational materials, which identified further educational needs applied to a web-based DA. Phase 3 will preliminarily evaluate the web-based DA: in a pilot RCT, 50 adults diagnosed with SKMs will receive the web-based DA or an existing web-based institutional website at urology clinics at a large academic medical center. The web-based DA applies risk communication and information about diagnosis and treatment options, elicits preferences regarding treatment options, and provides a set of options to consider with their doctor based on a decision-analytic model of benefits/harm analysis that accounts for comorbidity, age group, and tumor features. Questionnaires and treatment decision data will be gathered before and after viewing the educational material.

Results

This phase will consist of a pilot RCT from August 2022 to January 2023 to establish feasibility and preliminarily evaluate decision outcomes. Previous study phases from 2018 to 2020 supported the feasibility of providing the printed DA in urology clinics before clinical consultation and demonstrated increased patient knowledge about the diagnosis and treatment options and greater likelihood of favoring nonsurgical treatment just before consultation. This study was funded by the National Cancer Institute. Recruitment will begin in August 2022.

Conclusions

A web-based DA has been designed to address educational needs for patients making treatment decisions for SKM, accounting for comorbidities and treatment-related benefits and risks. Outcomes from the pilot trial will evaluate the potential of a web-based DA in personalizing treatment decisions and in helping patients weigh attributes of surgical versus nonsurgical treatment options for their SKMs.

Trial Registration

ClinicalTrials.gov NCT05387863; https://clinicaltrials.gov/ct2/show/NCT05387863

International Registered Report Identifier (IRRID)

PRR1-10.2196/41451

Clinical implications of 3D printing technology in preoperative evaluation of partial nephrectomy

OBJECTIVES

Renal cancer is a common malignancy of the urinary system, and the partial nephrectomy is a common surgical modality for early renal cancer. 3D printing technology can create a visual three-dimensional model by using 3D digital models of the patient's imaging data. With this model, surgeons can perform preoperative assessment to clarify the location, depth, and blood supply of the tumor, which helps to develop preoperative plans and achieve better surgical outcomes. In this study, the R.E.N.A.L scoring system was used to stratify patients with renal tumors and to explore the clinical application value of 3D printing technology in laparoscopic partial nephrectomy.

METHODS

A total of 114 renal cancer patients who received laparoscopic partial nephrectomy in Xiangya Hospital from June 2019 to December 2020 were enrolled. The patients were assigned into an experimental group (n=52) and a control group (n=62) according to whether 3D printing technology was performed, and the differences in perioperative parameters between the 2 groups were compared. Thirty-nine patients were assigned into a low-complexity group (4-6 points), 32 into a moderate-complexity group (7-9 points), and 43 into a high-complexity group (10-12 points) according to R.E.N.A.L score, and the differences in perioperative parameters between the experimental group and the control group in each score group were compared.

RESULTS

The experimental group had shorter operative time, renal ischemia time, and postoperative hospital stay (all P<0.05), less intraoperative blood loss (P=0.047), and smaller postoperative blood creatinine change (P=0.032) compared with the control group. In the low-complexity group, there were no statistically significant differences between the experimental group and the control group in operation time, renal ischemia time, intraoperative blood loss, postoperative blood creatinine changes, and postoperative hospital stay (all P>0.05). In the moderate- and high- complexity groups, the experimental group had shorter operative time, renal ischemia time, and postoperative hospital stay (P<0.05 or P<0.001), less intraoperative blood loss (P=0.022 and P<0.001, respectively), and smaller postoperative blood creatinine changes (P<0.05 and P<0.001, respectively) compared with the control group.

CONCLUSIONS

Compared with renal tumor patients with R.E.N.A.L score<7, renal cancer patients with R.E.N.A.L score≥7 may benefit more from 3D printing assessment before undergoing partial nephrectomy.

Predictors of Positive Surgical Margins after Robot-Assisted Partial Nephrectomy for Localized Renal Tumors: Insights from a Large Multicenter International Prospective Observational Project (The Surface-Intermediate-Base Margin Score Consortium)

Background: To explore predictors of positive surgical margins (PSM) after robotic partial nephrectomy (PN) in a large multicenter international observational project, harnessing the Surface-Intermediate-Base (SIB) margin score to report the resection technique after PN in a standardized way. Methods: Data from consecutive patients with cT1-2N0M0 renal masses treated with PN from September 2014 to March 2015 at 16 tertiary referral centers and included in the SIB margin score International Consortium were prospectively collected. For the present study, only patients treated with robotic PN were included. Uni- and multivariable analysis were fitted to explore clinical and surgical predictors of PSMs after PN. Results: Overall, 289 patients were enrolled. Median (IQR) preoperative tumor size was 3.0 (2.3−4.2) cm and median (IQR) PADUA score was 8 (7−9). SIB scores of 0−2 (enucleation), 3−4 (enucleoresection) and 5 (resection) were reported in 53.3%, 27.3% and 19.4% of cases, respectively. A PSM was recorded in 18 (6.2%) patients. PSM rate was 4.5%, 11.4% and 3.6% in case of enucleation, enucleoresection and resection, respectively. Patients with PSMs had tumors with a higher rate of contact with the urinary collecting system (55.6% vs. 27.3%; p < 0.001) and a longer median warm ischemia time (22 vs. 16 min; p = 0.02) compared with patients with negative surgical margins, while no differences emerged between the two groups in terms of other tumor features (i.e., pathological diameter, PADUA score). In multivariable analysis, only enucleoresection (SIB score 3−4) versus enucleation (SIB score 0−2) was found to be an independent predictor of PSM at final pathology (HR: 2.68; 95% CI: 1.25−7.63; p = 0.04), while resection (SIB score 5) was not. Conclusions: In our experience, enucleoresection led to a higher risk of PSMs as compared to enucleation. Further studies are needed to assess the differential impacts of resection technique and surgeon’s experience on margin status after robotic PN.

Clampless Laparoscopic Tumor Enucleation for Exophytic Masses Greater Than 4 cm: Is Renorrhaphy Necessary?

Objective: To demonstrate the safety of clampless 3D laparoscopic tumor enucleation (cLTE) for exophytic T1b kidney masses, avoiding suture to achieve hemostasis. Methods: Between January 2010 and January 2021, 241 consecutive patients with an exophytic renal tumor underwent sutureless cLTE. Patients with predominantly endophytic growth or tumors 4 mm closer to the collecting system less were excluded. In all cases, an attempt was made to accomplish surgery without suturing kidney parenchyma. Data were obtained from a retrospective review of history and physical examinations, operative and pathology reports, anesthesia records during the hospital stay, and follow-up visits. Results: Among 241 patients who underwent cLTE, 148 had cT1a and 93 had cT1b renal tumor. The median tumor size was 32 mm, and the median R.E.N.A.L. (radius exophytic/endophytic nearness anterior/posterior location) score was 6. Renorrhaphy was necessary in 5 cases. The median operative time (OT) was 100 minutes, and the estimated blood loss (EBL) was 150 mL. The median 24-hour decrease in hemoglobin was 1.8 g/dL. The median length of stay was 4 days. Nineteen patients had postoperative complications: 3 cases had Clavien-Dindo (CD) 3a or more, 6 had CD2, and 10 had CD1. Comparing the T1a and T1b groups, except for the median OT and the EBL, no significant differences were observed in all the other variables analyzed. In both groups, renal function was preserved after 1 year from surgery. Conclusion: Our experience showed that sutureless cLTE is safe and feasible for T1b tumors leading to radical oncological outcomes and preserving renal function.

Initial experience of robot-assisted radical nephrectomy in Japan: Single institutional study of 12 cases

INTRODUCTION

To evaluate the initial experience of robot-assisted radical nephrectomy (RARN) in a single institution in Japan.

METHODS

This study included a total of 12 patients with renal tumors who were not preoperatively regarded as optimal candidates for robot-assisted partial nephrectomy (RAPN) and subsequently treated with RARN between April 2019 and June 2021 at our institution. Comprehensive perioperative outcomes in these patients were retrospectively analyzed.

RESULTS

Of the 12 included patients, 10 and two were male and female, respectively, and the median age was 66 years. The median tumor diameter was 44 mm, and four, four and four patients were classified into cT1a, cT1b and cT3a, respectively. There was no patient requiring open conversion, and the median operative and console times were 167 and 79 minutes, respectively. The median estimated blood loss was 42 cc, and no patient required blood transfusion. During the perioperative period, no major complication corresponding to Clavien-Dindo grade ≥3 occurred. Nine, two and one patient were pathologically diagnosed with clear cell carcinoma (CCC), non-CCC and benign cyst, respectively, and there was no patient who developed recurrent diseases.

CONCLUSIONS

Considering complicated tumor characteristics not amenable to RAPN in this series, such as an intravenous tumor thrombus or previous history of open partial nephrectomy, perioperative outcomes of initial experience with RARN in Japan could be considered favorable. Collectively, these findings suggest that RARN may be a promising alternative to laparoscopic radical nephrectomy for patients with complicated renal tumors, contraindicated for RAPN.

Bilateral Renal Tumors in Children: The First 5 Years' Experience of National Centralization in The Netherlands and a Narrative Review of the Literature

Survival of unilateral Wilms tumors (WTs) is exceeding 90%, whereas bilateral WTs have an inferior outcome. We evaluated all Dutch patients with bilateral kidney tumors, treated in the first five years of national centralization and reviewed relevant literature. We identified 24 patients in our center (2015–2020), 23 patients had WT/nephroblastomatosis and one renal cell carcinoma. Patients were treated according to SIOP-RTSG protocols. Chemotherapy response was observed in 26/34 WTs. Nephroblastomatosis lesions were stable (n = 7) or showed response (n = 18). Nephron-sparing surgery was performed in 11/22 patients undergoing surgery (n = 2 kidneys positive margins). Local stage in 20 patients with ≥1 WT revealed stage I (n = 7), II (n = 4) and III (n = 9). Histology was intermediate risk in 15 patients and high risk in 5. Three patients developed a WT in a treated nephroblastomatosis lesion. Two of 24 patients died following toxicity and renal failure, i.e., respectively dialysis-related invasive fungal infection and septic shock. Genetic predisposition was confirmed in 18/24 patients. Our literature review revealed that knowledge is scarce on bilateral renal tumor patients with metastases and that radiotherapy seems important for local stage III patients. Bilateral renal tumors are a therapeutic challenge. We describe management and outcome in a national expert center and summarized available literature, serving as baseline for further improvement of care.

Low Lymphocyte-to-Monocyte Ratio Is the Potential Indicator of Worse Overall Survival in Patients with Renal Cell Carcinoma and Venous Tumor Thrombus

The purpose of the study was to determine the influence of lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR) values on the prognosis in patients with renal cell carcinoma (RCC) and venous tumor thrombus. The respective data of 91 patients treated with radical surgery in the years 2012-2021 in 2 tertiary referral urological centers were retrieved from local medical databases. Mean calculated 3-year overall survival (OS) reached 70% (mean follow-up 35.3 months). The association between lower LMR and the presence of tumor necrosis (p = 0.0004) was observed. Amongst systemic inflammatory markers, only LMR was selected as the sensitive marker predicting death with a calculated cut-off value of 2.53. OS was decreased in patients presenting with low LMR when compared to the high LMR group (39% vs. 82%, p = 0.0011). Neither NLR nor PLR were associated with survival rates. In multivariate analysis, LMR was identified as the independent prognostic factor (HR = 0.20, 95% CI 0.07-0.55, p = 0.001). Low values of LMR (<2.53) are independently connected with poorer OS in patients with RCC and coexisting tumor thrombus. The incorporation of the hematological variables into the prognostic model greatly increased its accuracy in predicting survival in the distinctive subpopulation of patients with RCC.

Perioperative management including dual cell salvage in a Jehovah's Witness patient undergoing major urological surgery

Complex surgery associated with major hemorrhage presents particular risks for Jehovah's Witnesses who do not accept transfusion of blood products. Intraoperative use of two cell saver machines simultaneously can maximize the yield of salvaged blood from both the operative field and from washed surgical swabs and can potentially be life-saving.

Differentiating Benign from Malignant Renal Tumors Using T2- and Diffusion-Weighted Images: A Comparison of Deep Learning and Radiomics Models Versus Assessment from Radiologists

BACKGROUND

Differentiating benign from malignant renal tumors is important for selection of the most effective treatment.

PURPOSE

To develop magnetic resonance imaging (MRI)-based deep learning (DL) models for differentiation of benign and malignant renal tumors and to compare their discrimination performance with the performance of radiomics models and assessment by radiologists.

STUDY TYPE

Retrospective.

POPULATION

A total of 217 patients were randomly assigned to a training cohort (N = 173) or a testing cohort (N = 44).

FIELD STRENGTH/SEQUENCE

Diffusion-weighted imaging (DWI) and fast spin-echo sequence T2-weighted imaging (T2WI) at 3.0T.

ASSESSMENT

A radiologist manually labeled the region of interest (ROI) on each image. Three DL models using ResNet-18 architecture and three radiomics models using random forest were developed using T2WI alone, DWI alone, and a combination of the two image sets to discriminate between benign and malignant renal tumors. The diagnostic performance of two radiologists was assessed based on professional experience. We also compared the performance of each model and the radiologists.

STATISTICAL TESTS

The area under the receiver operating characteristic (ROC) curve (AUC) was used to assess the performance of each model and the radiologists. P < 0.05 indicated statistical significance.

RESULTS

The AUC of the DL models based on T2WI, DWI, and the combination was 0.906, 0.846, and 0.925 in the testing cohorts, respectively. The AUC of the combination DL model was significantly better than that of the models based on individual sequences (0.925 > 0.906, 0.925 > 0.846). The AUC of the radiomics models based on T2WI, DWI, and the combination was 0.824, 0.742, and 0.826 in the testing cohorts, respectively. The AUC of two radiologists was 0.724 and 0.667 in the testing cohorts.

CONCLUSION

Thus, the MRI-based DL model is useful for differentiating benign from malignant renal tumors in clinic, and the DL model based on T2WI + DWI had the best performance.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2.

MRI Characteristics of Pediatric Renal Tumors: A SIOP-RTSG Radiology Panel Delphi Study

BACKGROUND

The SIOP-Renal Tumor Study Group (RTSG) does not advocate invasive procedures to determine histology before the start of therapy. This may induce misdiagnosis-based treatment initiation, but only for a relatively small percentage of approximately 10% of non-Wilms tumors (non-WTs). MRI could be useful for reducing misdiagnosis, but there is no global consensus on differentiating characteristics.

PURPOSE

To identify MRI characteristics that may be used for discrimination of newly diagnosed pediatric renal tumors.

STUDY TYPE

Consensus process using a Delphi method.

POPULATION

Not applicable.

FIELD STRENGTH/SEQUENCE

Abdominal MRI including T1- and T2-weighted imaging, contrast-enhanced MRI, and diffusion-weighted imaging at 1.5 or 3 T.

ASSESSMENT

Twenty-three radiologists from the SIOP-RTSG radiology panel with ≥5 years of experience in MRI of pediatric renal tumors and/or who had assessed ≥50 MRI scans of pediatric renal tumors in the past 5 years identified potentially discriminatory characteristics in the first questionnaire. These characteristics were scored in the subsequent second round, consisting of 5-point Likert scales, ranking- and multiple choice questions.

STATISTICAL TESTS

The cut-off value for consensus and agreement among the majority was ≥75% and ≥60%, respectively, with a median of ≥4 on the Likert scale.

RESULTS

Consensus on specific characteristics mainly concerned the discrimination between WTs and non-WTs, and WTs and nephrogenic rest(s) (NR)/nephroblastomatosis. The presence of bilateral lesions (75.0%) and NR/nephroblastomatosis (65.0%) were MRI characteristics indicated as specific for the diagnosis of a WT, and 91.3% of the participants agreed that MRI is useful to distinguish NR/nephroblastomatosis from WT. Furthermore, all participants agreed that age influenced their prediction in the discrimination of pediatric renal tumors.

DATA CONCLUSION

Although the discrimination of pediatric renal tumors based on MRI remains challenging, this study identified some specific characteristics for tumor subtypes, based on the shared opinion of experts. These results may guide future validation studies and innovative efforts.

LEVEL OF EVIDENCE

3 Technical Efficacy Stage: 3.

The efficacy evaluation of partial nephrectomy with selective renal artery branch occlusion by laparoscopy

BACKGROUND

To investigate the clinical application and effect of laparoscopic partial nephrectomy with renal artery branch occlusion in the treatment of early renal tumors.

METHODS

A retrospective analysis was conducted on the clinical data of 15 cases of renal tumor patients who underwent partial nephrectomy by laparoscopic selective renal artery branch occlusion in our department from January 2017 to January 2018. Nine male patients and 6 female patients were aged 46 to 65 years, with an average age of 54.3 ± 7.2 years. The diameters of tumors were 2.2 to 4.0 cm, with an average of 3.3 ± 0.7 cm. There are 10 tumors locating on the left side and 5 on the right side. Preoperative renal glomerular filtration rate (GFR) were 77.3 to 61.9 mL/min with an average of 47.6 ± 7.5 mL/min. All patients' diseased kidneys underwent renal computer tomography angiography examination before surgery. And the diseased kidney underwent reexamination of renal GFR. The operation time, renal artery branch occlusion time, intraoperative blood loss, postoperative hospital stay, changes of renal function, and complications were evaluated.

RESULTS

All surgery were completed successfully, the surgery time was 136.7 ± 15.2 min, intraoperative renal artery branch occlusion time was 21.3 ± 4.5 min, the intraoperative blood loss was 223.3 ± 69.5 mL, the postoperative hospital stay was 6.5 ± 1.7 days, and the postoperative 1-month GFR was 49.5 ± 6.6 mL/min. There was no significant difference between the renal GFR before and after surgery (P > .05). There was no blood transfusion and transfer open surgery cases. The patients were followed up for 3 to 15 months without complications.

CONCLUSIONS

Partial nephrectomy with selective renal artery branch occlusion by laparoscopy is a safe, feasible, and effective method for the treatment of early renal cancer. It makes good use of the technical advantages of clear operation field and fine operation of laparoscopic surgery, avoids the heat ischemia process of the whole kidney, and can better protect the renal function.

Oncological Outcomes of Patients With Different Pathological Features of pT3a Renal Tumor: A Systematic Review and Quantitative Synthesis

Purpose

To identify the differences in oncological outcomes for patients with different pT3a renal tumor invasion patterns and pathological features.

Methods

The protocol of this study was registered on PROSPERO (CRD42021234475). Relevant studies were identified by searching the PubMed, Cochrane library, Embase, and Web of Science databases. Cancer-specific survival (CSS) was selected as the endpoint. Pooled hazard ratio (HR) and 95% confidence interval (CI) extracted from multivariate Cox models were evaluated to identify the hazard association.

Results

A total of 22 studies, which enrolled 12384 patients were included for quantitative synthesis. Sinus fat invasion (SFI) + perinephric fat invasion (PFI) was associated with inferior CSS compared to SFI only (p = 0.02). Comparable CSS was observed between SFI and PFI (p = 0.57). SFI ± PFI showed inferior CSS compared to PFI only (p = 0.0002). The presence of pelvicalyceal system invasion significantly increased the risk of cancer-specific mortality (p = 0.0005). Renal vein invasion (RVI) indicated poor oncological outcomes in terms of CSS (p = 0.002). The concomitant RVI and fat invasion (FI) significantly increased the risk of deterioration of CSS compared to RVI or FI (p < 0.0001). Multiple invasion patterns translated into a significantly decreased CSS (p < 0.0001). Aggressive tumor behavior, including lymph node involvement (p = 0.006), distant metastases (p < 0.00001), sarcomatoid differentiation (p < 0.0001), necrosis (p < 0.0001), Fuhrman grade III or IV (p < 0.0001), positive margin (p < 0.0001), and tumor size >7cm (p < 0.0001) were the predictors of inferior CSS. The lymphovascular invasion (p = 0.67) was indolent in terms of CSS.

Conclusion

This study confirmed the heterogenicity of pT3a renal tumors. Multiple invasion patterns could translate into a significantly decreased CSS, and SFI should not be merged in the SFI + PFI group. The presence of PSI or RVI could significantly increase the risk of cancer-specific mortality. Lymph node involvement, distant metastases, sarcomatoid differentiation, necrosis, high Fuhrman grade, positive margin, and size >7cm were the predictors of inferior CSS. A precise-risk grade of CSS for different invasion patterns including comprehensive combinations may be useful for the further refinements of the TNM system.

Systematic Review Registration

The current study was registered on PROSPERO, and the registration numbers is CRD42021234475.

[Unilateral combined lap partial nephrectomy and pyelolithotomy for ipsilateral tumor & kidney staghorn stone]

OBJECTIVE

To discuss the feasibility, safety, and effectiveness of conventional laparoscopic partial nephrectomy combined with pyelolithotomy for patients with ipsilateral renal tumor and staghorn kidney stone.

MATERIALS AND METHODS

Retrospective multicentral comparative study. Group "Combo" was presented by patients with the mentioned combined pathology (n=15). Group "Standart" (n=69) formed from common patients who underwent standard lap partial nephrectomy for renal tumor in the absence of kidney stones. Perioperative factors and results were studied and compared. Video presentation of combined surgical technique is available at: https://youtu.be/fAfYJDvGzsU.

RESULTS

Of all patients, no positive margins, no conversions to open surgery or nephrectomy & any complications Clavien >III were detected. There were no any significant differences between the two groups except for OR time (150 [120; 210] vs 130 [100; 180] min; p=0,001). Differences between indexes of WIT (16,27+/-3,8 vs 15,9+/-4,5 min; p=0,107), EBL (200 [150; 300] vs 200 [150; 300] cc; p=0,981), length of stay (7 [6;9] vs 8[6;9] days; p=0,611), intraop complications (0,00 vs 4,3%; p=0,411) and values of postop Clavien III rate (0,00 vs 4,3%; p=0,411) for "Combo" & "Standart" respectively were comparable as well as oncological outcomes. Stone-free rate for combined procedures reached 93,3%.

CONCLUSION

conventional laparoscopic partial nephrectomy combined with pyelolithotomy for patients with ipsilateral renal tumor and staghorn kidney stone is safe and efficient alternative to 2-step treatment of this rare disease.

The Influence of Prior Abdominal Surgery on Robot-Assisted Partial Nephrectomy

Background

We evaluated the influence of prior abdominal surgery on perioperative outcomes in patients who underwent robot-assisted partial nephrectomy in initial Japanese series.

Methods

We reviewed patients with small renal tumors who underwent robot-assisted partial nephrectomy from October 2011 to September 2020 at our institution. Patients with prior abdominal surgery were compared with those without prior surgery based on perioperative outcomes. The chi-square test and Mann-Whitney U test were used for statistical analyses of variables.

Results

Of 156 patients who underwent robot-assisted partial nephrectomy, 90 (58%) had no prior abdominal surgery, whereas 66 patients (42%) underwent prior abdominal surgery. No significant differences in perioperative outcomes were observed between with and without prior abdominal surgery groups. In transperitoneal approach robot-assisted partial nephrectomy, 31 patients (80.4%) had prior abdominal surgery. Trocar insertion time in the with prior abdominal surgery group took longer than the without prior abdominal surgery group (32 vs. 28.5 min, P = 0.031). No significant difference was observed in the conversion rate between the two groups (P = 0.556).

Conclusion

Robot-assisted partial nephrectomy appears to be a safe approach for patients with prior abdominal surgery. In transperitoneal approach robot-assisted partial nephrectomy with prior abdominal surgery, trocar insertion time was longer, but no significant differences were found in other outcomes. Transperitoneal approach robot-assisted partial nephrectomy is thus considered a safe procedure for patients with prior abdominal surgery.

[Unilateral combination of staghorn stone with kidney tumor]

This manuscript provides an overview of the available literature about unilateral combination of nephrolithiasis and renal tumor. Analysis of publications has shown that ipsilateral staghorn calculus and kidney tumors are an extremely rare combination. The majority of these infrequent papers describe case reports where the method of treating such patients is limited by the capabilities and competence of the surgeon or clinic. Despite some messages of favorable outcomes of combined interventions, the effectiveness of simultaneous laparoscopic partial nephrectomy and pyelolithotomy has not been studied, and the technique of this procedure, tactics and criteria for choosing this method are not defined.

Application of low-dose CT to the creation of 3D-printed kidney and perinephric tissue models for laparoscopic nephrectomy

PURPOSE

The aim of this study was to explore the feasibility of 3D printing of kidney and perinephric fat based on low-dose CT technology.

PATIENTS AND METHODS

A total of 184 patients with stage T1 complex renal tumors who underwent laparoscopic nephrectomy were prospectively enrolled and divided into three groups: group A (conventional dose kidney and perinephric fat 3D printing group, n = 62), group B (low-dose kidney and perinephric fat 3D printing, n = 64), and group C (conventional dose merely kidney 3D printing group, n = 58). The effective dose (ED), signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were determined. The 3D printing quality was evaluated using a 4-point scale, and interobserver agreement was assessed using the intraclass correlation coefficient (ICC).

RESULTS

The ED of group B was lower than that of group A, with a decrease of 55.1%. The subjective scores of 3D printing quality in all groups were 3 or 4 points. The interobserver agreement among the three observers in 3D printing quality was good (ICC = 0.84-0.92). The perioperative indexes showed that operation time (OT), warm ischemia time (WIT), estimated blood loss (EBL), and laparoscopic partial nephrectomy (LPN) conversion to laparoscopic radical nephrectomy (LRN) in groups A or B were significantly less than those in group C. LPN was more frequent in group A and group B than in group C (all p < 0.017). There were no significant differences in perioperative indexes between group A and group B (all p > 0.017).

CONCLUSION

Low-dose CT technology can be effectively applied to 3D printing of kidney and perinephric fat and reduce the patient's radiation dose without compromising 3D printing quality. 3D printing of kidney and perinephric fat can significantly increase the success rate of LPN and decrease OT, WIT, and EBL.

Metastatic renal Ewing's sarcoma in adult woman: Case report and review of the literature

Primary renal extra-skeletal Ewing sarcoma is a rare neoplasm, often metastatic at diagnosis, and with a poor outcome. A multimodal approach is often the treatment of choice in this aggressive neoplasm. We present a case of primary renal extra-skeletal sarcoma in a 45-year-old woman who underwent tumor resection without clear margins. After no response to the first cycle of chemotherapy, we documented an early onset of local recurrence. The patient refused any other treatment and died four months after surgery.