Excisional Precision Matters: Understanding the Influence of Excisional Volume Loss on Renal Function After Partial Nephrectomy

Impact of Robotic-Assisted Partial Nephrectomy with Single Layer versus Double Layer Renorrhaphy on Postoperative Renal Function

We aimed to investigate the differences in renal function between patients who underwent single inner-layer renorrhaphy (SILR) or double-layer renorrhaphy (DLR) among those with renal tumors who underwent robot-assisted partial nephrectomy (RAPN). This retrospective multicenter cohort study was conducted between November 2018 and October 2023 at two institutions and included patients who underwent RAPN. In total, 93 eligible patients who underwent RAPN were analyzed. Preoperative renal function and prevalence of chronic kidney disease were not significantly different between the two groups. Although urinary leakage was observed in three patients (5.9%) in the SILR group, there was no significant difference between the two groups regarding surgical outcomes (p = 0.249). Serum creatinine levels after RAPN were significantly lower in the SILR group than in the DLR group on postoperative days 1 and 365 following RAPN (p = 0.04). The estimated glomerular filtration rate (eGFR) was significantly lower in the DLR group than in the SILR group only on postoperative day 1; however, there was no significant difference between the two groups thereafter. Multivariate analysis showed that the method of renorrhaphy was not a predictor for maintaining renal function after RAPN even though it was associated with eGFR on postoperative day 1.

Partial nephrectomy for renal tumors: recommendations of the Italian Society of Urology RCC working group

INTRODUCTION

Partial nephrectomy (PN) aims to remove renal tumors while preserving renal function without affecting oncological and perioperative surgical outcomes. Aim of this paper is to summarize the current evidence on PN and to provide evidence-based recommendations on indications, surgical technique, perioperative management and postoperative surveillance of PN for renal tumors in the Italian clinical and health care system context.

EVIDENCE ACQUISITION

This review is the result of an interactive peer-reviewing process of the recent literature on PN for renal tumors carried out by an expert panel composed of members of the Italian Society of Urology (SIU) Renal Cell Carcinoma Working Group.

EVIDENCE SYNTHESIS

PN for localized renal tumors is not inferior to radical nephrectomy in terms of survival outcomes while significantly better preserving renal function. Loss of renal function after PN is influenced by medical comorbidities/preoperative renal function and surgical variables such volume of parenchyma preserved and ischemia time. Urologists should select the clamping strategy during PN based on their experience and patient-specific factors. PN can be performed with any surgical approach based on surgeon's expertise and skills. Robotic PN has the potential to expand the minimally invasive indications without interfering with oncological outcomes. The use of 3D virtual models, real time ultrasound and fluorescence tools to assess the anatomy and vascularization of renal tumors during PN may allow a more accurate preoperative planning and intraoperative guidance. Proper postoperative surveillance protocols are essential to detect tumor recurrences and assess functional outcomes.

CONCLUSIONS

PN is the standard of care for treatment of localized T1 renal tumors. Recent data supports PN also for selected T2-T3a tumors in experienced institutions. Careful preoperative planning, adequate surgical skills and volumes and appropriate postoperative management and surveillance are paramount to optimize PN oncological and functional outcomes.

Volumetric and functional outcomes at 1-year between percutaneous-ablation and partial-nephrectomy for T1b renal tumors

INTRODUCTION

Indication for percutaneous-ablation (PA) is gradually expanding to renal tumors T1b (4-7cm). Few data exist on the alteration of renal functional volume (RFV) post-PA. Yet, it is a surrogate marker of post partial-nephrectomy (PN) glomerular filtration rate (GFR) impairment. The objective was to compare RFV and GFR at 1-year post-PN or PA, in this T1b population.

METHODS

Patients with unifocal renal tumor≥4cm treated between 2014 and 2019 were included. Tumor, homolateral (RFVh), contralateral RFV, and total volumes were assessed by manual segmentation (3D Slicer) before and at 1 year of treatment, as was GFR. The loss of RFV, contralateral hypertrophy, and preservation of GFR were compared between both groups (PN vs. PA).

RESULTS

144 patients were included (87PN, 57PA). Preoperatively, PA group was older (74 vs. 59 years; P<0.0001), had more impaired GFR (73 vs. 85mL/min; P=0.0026) and smaller tumor volume(31.1 vs. 55.9cm3; P=0.0007) compared to PN group. At 1 year, the PN group had significantly more homolateral RFV loss (-19 vs. -14%; P=0.002), and contralateral compensatory hypertrophy (+4% vs. +1,8%; P=0.02, respectively). Total-RFV loss was similar between both (-21.7 vs. -19cm3; P=0.07). GFR preservation was better in the PN group (95.9 vs. 90.7%; P=0.03). In multivariate analysis, age and tumor size were associated with loss of RFVh.

CONCLUSION

For renal tumors T1b, PN is associated with superior compensatory hypertrophy compared with PA, compensating for the higher RFVh loss, resulting in similar ΔRFV-total between both groups. The superior post-PN GFR preservation suggests that the preserved quantitative RFV factor is insufficient. Therefore, the underlying quality of the parenchyma would play a major role in postoperative GFR.

Comparison of transperitoneal and retroperitoneal partial nephrectomy with single port robot

PURPOSE

To investigate the efficacy and safety of single port robotic transperitoneal (TP) and retroperitoneal (RP) partial nephrectomy.

MATERIALS AND METHODS

From September 2021 to June 2022, 30 sequential cases of partial nephrectomy performed after a single port (SP) robot was introduced to our hospital were retrospectively analyzed. All patients were diagnosed with T1 renal cell carcinoma and operated by a single expert in conventional robot with a da Vinci SP platform.

RESULTS

A total of 30 patients underwent SP robotic partial nephrectomy, including 16 (53.33%) by TP and 14 (47.67%) by RP. Body mass index was slightly higher in the TP group (25.37 vs. 23.53, p-value = 0.040). Other demographic characteristics were not significantly different between the two groups. There was no statistically significant difference in ischemic time (727.41 ± 561.18 sec for TP and 698.56 ± 299.23 sec for RP, p-value = 0.812) or console time (67.97 ± 24.06 min for TP and 69.71 ± 28.66 min for RP, p-value = 0.724). There was no statistically significant difference in perioperative or pathological outcome either. Renal function calculated from DTPA was 103.33 ml/min/1.73m2 for TP and 101.33 ml/min/1.73m2 for RP (p-value = 0.214) postoperatively. It was 90.36 ml/min/1.73m2 for TP and 87.74 ml/min/1.73m2 for RP (p-value = 0.592) at 90 days after surgery.

CONCLUSION

SP robot partial nephrectomy can be performed effectively and safely regardless of the approach. Both TP and RP approaches offer similar perioperative and postoperative outcomes for T1 RCC.

Every decade counts: a narrative review of functional recovery after partial nephrectomy

OBJECTIVE

To provide a narrative review of the major advances regarding ischaemia and functional recovery after partial nephrectomy (PN), along with the ongoing controversies.

METHODS

Key articles reflecting major advances regarding ischaemia and functional recovery after PN were identified. Special emphasis was placed on contributions that changed perspectives about surgical management. Priority was also placed on randomized trials of off-clamp vs on-clamp cohorts.

RESULTS

A decade ago, 'Every minute counts' was published, showing strong correlations between duration of ischaemia and development of acute kidney injury (AKI) and chronic kidney disease after clamped PN. This reinforced perspectives that ischaemia was the main modifiable factor that could be addressed to improve functional outcomes and helped spur efforts towards reduced or zero ischaemia PN. These approaches were associated with strong functional recovery and some peri-operative risk, although they were generally safe in experienced hands. Further research demonstrated that, when parenchymal volume changes were incorporated into the analyses, ischaemia lost statistical significance, and percent parenchymal volume saved proved to be the main determinant. Cold ischaemia was confirmed to be highly protective, and limited warm ischaemia also proved to be safe. The reconstructive phase of PN, with avoidance of parenchymal devascularization, appears to be most important for functional outcomes. Randomized trials of on-clamp vs off-clamp PN have shown minimal impact of ischaemia on functional recovery.

CONCLUSIONS

The past decade has witnessed great progress regarding functional recovery after PN, with many lessons learned. However, there are still unanswered questions, including: What is the threshold of warm ischaemia at which irreversible ischaemic injury begins to develop? Are some cohorts at increased risk for AKI or irreversible ischaemic injury? and Which patients should be prioritized for zero-ischaemia PN?

The efficacy of modified binding technique for renorrhaphy during robotic partial nephrectomy: surgical and functional outcomes from single-center experience

BACKGROUND

To compare the traditional single-layer and double-layer suture renorrhaphy with modified "Binding" suture renorrhaphy (whole rim of the wound was closed by the all-layer flow suture starting from the parenchyma cut edges to hilum, followed by the final defect closure) in robotic partial nephrectomy (RPN) for treating localized renal cell carcinoma in our large institutional experience.

METHODS

We retrospectively reviewed clinical data of 406 consecutive patients who underwent RPN from May 2018 and December 2020 in our center. The demographic and oncologic outcome variables were compared between different renal reconstruction groups and the effect of these suture techniques on renal function outcomes was also evaluated.

RESULTS

For the single-layer group, median operative time and warm ischemic time were significantly less than that of the double-layer and "Binding" groups (p < 0.001), while the significantly lower eGFR drop (p = 0.014) was also detected within postoperative 3 months from baseline, but this difference lost its statistical significance from 3th month to the last follow-up. The changes in postoperative creatinine values were clinically insignificant among the three groups. In a sub-analysis over 258 patients with moderate/high nephrometry score, those patients who underwent "Binding" suture had an undifferentiated warm ischemic time, estimated blood loss, and length of hospitalization stay with a decreased risk of Grade III complications (postoperative hemorrhage requiring intervention) and improved renal function recovery during the whole follow-up.

CONCLUSION

Single-layer suture renorrhaphy may be associated with better renal functional preservation and could prove to be reliable in patients with low-complexity tumor (RENAL score ≤ 6). Patients with moderate/high-complexity tumor (RENAL score ≥ 7) might represent a subgroup of patients having a functional benefit after "Binding" suture renorrhaphy even in the long-term period.

Effect of augmented reality navigation technology on perioperative safety in partial nephrectomies: A meta-analysis and systematic review

Aim

To evaluate the impact of augmented reality surgical navigation (ARSN) technology on short-term outcomes of partial nephrectomy (PN).

Methods

A systematic literature search was conducted in PubMed, Embase, Cochrane, and Web of Science for eligible studies published through March 28, 2022. Two researchers independently performed the article screening, data extraction and quality review. Data analysis was performed using Cochrane Review Manager software.

Results

A total of 583 patients from eight studies were included in the analysis, with 313 in the ARSN-assisted PN group (AR group) and 270 in the conventional PN group (NAR group). ARSN-assisted PN showed better outcomes than conventional surgery in terms of operative time, estimated blood loss, global ischemia rate, warm ischemia time, and enucleation rate. However, there were no significant differences in the rate of Conversion to radical nephrectomy (RN), postoperative estimated glomerular filtration rate (eGFR), positive margin rate, and postoperative complication rate.

Conclusion

The utilization of ARSN can improve the perioperative safety of PN. Compared with conventional PN, ARSN-assisted PN can reduce intraoperative blood loss, shorten operative time, and improve renal ischemia. Although direct evidence is lacking, our results still suggest a potential advantage of ARSN in improving renal recovery after PN. However, as the ARSN system is still in an exploratory stage, its relevance in PN have been poorly reported. Additional high-quality randomized controlled trial (RCT) studies will be required to confirm the effect of ARSN on PN.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=301798, identifier PROSPERO ID: CRD42022301798.

Clinical Benefits of Indocyanine Green Fluorescence in Robot-Assisted Partial Nephrectomy

Background: To compare the intraoperative and postoperative outcomes of indocyanine green (ICG) administration in robot-assisted partial nephrectomy (RAPN) and report the differences in the results between patients with benign and malignant renal tumors. Methods: From 2017 to 2020, 132 patients underwent RAPN at our institution, including 21 patients with ICG administration. Clinical data obtained from our institution’s RAPN database were retrospectively reviewed. Intraoperative, postoperative, pathological, and functional outcomes of RAPN were assessed. Results: The pathological results indicated that among the 127 patients, 38 and 89 had received diagnoses of benign and malignant tumors, respectively. A longer operative time (311 vs. 271 min; p = 0.006) but superior preservation of estimated glomerular filtration rate (eGFR) at 3-month follow-up (90% vs. 85%; p = 0.031) were observed in the ICG-RAPN group. Less estimated blood loss, shorter warm ischemia time, and superior preservation of eGFR at postoperative day 1 and 6-month follow-up were also noted, despite no significant differences. Among the patients with malignant tumors, less estimated blood loss (30 vs. 100 mL; p < 0.001) was reported in the ICG-RAPN subgroup. Conclusions: Patients with ICG-RAPN exhibited superior short-term renal function outcomes compared with the standard RAPN group. Of the patients with malignant tumors, ICG-RAPN was associated with less blood loss than standard RAPN without a more positive margin rate. Further studies with larger cohorts and prospective designs are necessary to verify the intraoperative and functional advantages of the green dye.

Temporal Study of Renal Volume Losses in Patients with Robotic Partial Nephrectomies

Purpose: Robotic partial nephrectomies (RPNs) by their nature are associated with renal volume loss. Our goal of this study is to examine renal volume loss over time post partial nephrectomy. Materials and Methods: Fifty patients were followed for 1-year post-RPN with two-layer renorrhaphy and the sliding clip technique. This was done with a preoperative CT scan to assess renal mass and location. Patients post-RPN were imaged at time points 3 days, 6 months, and 12 months. Results: Patient demographics were 82% men with a median (interquartile range [IQR]) age of 57 (45-67) years and all were of Japanese descent. The medians (IQR) for warm ischemia time were 18 minutes (14-22), total operative time was 181.5 minutes (169.3-218.5), and estimated blood loss was 20 mL (10-50). The tumor characteristics had a median (IQR) diameter of 2.8 cm (2.5-3.4) with a RENAL score of 7 (6-8). The renal CT showed median (IQR) volume losses at 3 days of -1% (-7.1, 1.8), at 6 months of -15.3% (-20.6, -11.2), and at 12 months of -16.3% (-19.0, -12.8). Significance was seen at the 3 days to 6 months comparison for volume loss (p < 0.0001). Mean (standard deviation) estimated glomerular filtration rate (GFR) losses were as follows: at discharge 0.5% (12.9), 1 month -6.4% (11.8), 6 months -4.6% (9.8), and 12 months -3.6% (11.9). Statistical analysis showed significance for GFR loss at the comparison between discharge to 1 and 6 months (p = 0.01, p = 0.04). Conclusion: The initial volume loss seen postsurgery from resected healthy tissue was not significant and only became relevant at longer time points, suggesting that loss could be from atrophy. Volume loss over time supports the hypothesis that suture renorrhaphy is a primary cause of volume loss when warm ischemia time is <25 minutes.

Is Hypertension Associated with Worse Renal Functional Outcomes after Minimally Invasive Partial Nephrectomy? Results from a Multi-Institutional Cohort

Background: Hypertension (HTN) is a global public health issue. There are limited data regarding the effects of HTN in patients undergoing partial nephrectomy (PN) for renal tumors. To address this void, we tested the association between HTN and renal function after minimally invasive PN (MIPN). Methods: Using a multi-institutional database (2007–2017), we identified patients aged ≥ 18 years with a diagnosis of cT1 renal tumors treated with MIPN. Kaplan–Meier plots and Cox regression models addressed newly-onset CKD stage ≥ 3b or higher (sCKD). All analyses were repeated after 1:1 propensity score matching (PSM). Results: Overall, 2144 patients were identified. Of those, 35% (n = 759) were yes-HTN. Yes-HTN patients were older, more frequently male and more often presented with diabetes. Yes-HTN patients harbored higher RENAL nephrometry scores and higher cT stages than no-HTN patients. Conversely, yes-HTN patients exhibited lower preoperative eGFRs. In the overall cohort, five-year sCKD-free survival was 86% vs. 94% for yes-HTN vs. no-HTN, which translated into a multivariable HR of 1.67 (95% CI: 1.06–2.63, p = 0.026). After 1:1 PSM, virtually the same results were observed (HR 1.86, 95% CI: 1.07–3.23, p = 0.027). Conclusions: Yes-HTN patients exhibited worse renal function after MIPN when compared to their no-HTN counterparts. However, these observations need to be further tested in a prospective cohort study.

Short-Term and Long-Term Renal Outcomes in Patients With Obesity After Minimally Invasive Versus Open Partial Nephrectomy for the Treatment of Renal Cancer: Retrospective Study

Background

Obesity is significantly associated with renal cell carcinoma. Surgery is the preferred treatment for demarcated lesions of renal cell carcinoma; however, obesity increases the complexity of surgical outcomes. Minimally invasive surgical techniques are preferred over open partial nephrectomy (OPN), but controversy remains regarding the most efficacious technique in patients with obesity.

Objective

This study aims to determine whether minimally invasive partial nephrectomy (MIPN) or OPN better preserves renal function and investigate short- and long-term renal outcomes in patients with obesity undergoing a partial nephrectomy.

Methods

We conducted a retrospective chart review of 242 adult patients aged ≥18 years who underwent MIPN or OPN between January 1, 2005, and December 31, 2016, at the University of Arkansas for Medical Sciences. Using creatinine as a measure of kidney function, patients’ preoperative levels were compared with their postoperative levels in 2-time frames: short (3-6 months postsurgery) or long (>6 months). The primary outcome was the change in creatinine values from preoperative to >6 months postoperatively in patients with obesity. Secondary outcomes included the change in creatinine values from preoperative to 3 to 6 months postoperatively in patients with obesity who underwent MIPN versus OPN. We also analyzed the creatinine values of nonobese patients (BMI <30) who underwent partial nephrectomy using the same time frames. Unconditional logistic regression was used to estimate crude and multivariable-adjusted odds ratios (ORs) and 95% CI to observe associations between surgery type and changes in creatinine values from while stratifying for obesity.

Results

A total of 140 patients were included in the study, of whom 75 were obese and 65 were nonobese. At >6 months after MIPN (n=20), the odds of patients with obesity having a decrease or no change in creatinine values was 1.24 times higher than those who had OPN (n=13; OR 1.24, 95% CI 0.299-6.729; P=.80). At 3 to 6 months after MIPN (n=27), the odds were 0.62 times lower than those after OPN (n=17; OR 0.62, 95% CI 0.140-2.753; P=.56). In the nonobese group, at 3 to 6 months after undergoing minimally invasive surgery (n=18), the odds of having a decrease or no change in creatinine values was 4.86 times higher than those who had open surgery (n=21; OR 4.86, 95% CI 1.085-21.809; P=.04). At more than 6 months after MIPN (n=14), the odds were 4.13 times higher than those after OPN (n=11; OR 4.13, 95% CI 0.579-29.485; P=.16).

Conclusions

We observed a nonstatistically significant preservation of renal function in patients with obesity who underwent OPN at 3 to 6 months postoperatively. Conversely, after 6 months, the same was true for MIPN, indicating the long-term benefit of MIPN. In the nonobese group, MIPN was favored over OPN. 

Parenchymal Mass Loss During Partial Nephrectomy: Role of Devascularized Parenchymal Mass and Excised Parenchymal Mass and Impact on Functional Preservation

This study included 93 patients with renal masses who underwent standard partial nephrectomy or tumor enucleation. After surgery, parenchymal mass loss caused by devascularization resulted in more damage to renal function than excised parenchymal mass loss. Surgeons should seek better techniques to decrease devascularization during reconstruction.

INTRODUCTION

To evaluate the importance of devascularized parenchymal mass(DPM) and excised parenchymal mass(EPM) in functional preservation after standard partial nephrectomy(SPN).

PATIENTS AND METHODS

Forty-one patients who underwent pure tumor enucleation(TE) and 52 patients who underwent SPN with necessary data were included. As no EPM was lost in TE, the TE samples were used to estimate the degree of volume shrinkage that occurred when the measurements were performed in vivo with blood flow versus ex vivo without, and the shrinkage ratio was calculated as specimen volume divided by tumor volume in vivo. In SPN, the specimen volume comprised tumor volume plus EPM. The EPM was calculated as specimen volume divided by shrinkage ratio minus tumor volume in vivo. The DPM was defined as total ipsilateral parenchymal mass loss minus EPM. T tests, χ² test, and Mann-Whitney U tests were employed to compare clinical characteristics. Multivariate analysis was used to identify variables that correlated with glomerular filtration rate(GFR) preservation.

RESULTS

The mean sizes of devascularized and excised parenchymal masses were 13.6 cm³ and 5.2 cm³ (P = .01), which accounted for 7.8% and 3.4% of preoperative ipsilateral parenchymal mass (P = .03) in SPN, respectively. The shrinkage ratio was 0.71 and correlation coefficient was 0.965. After stepwise regression, DPM, and preoperative GFR were significantly associated with global GFR preservation.

CONCLUSION

The DPM comprises most of parenchymal mass loss after SPN and plays a more important role than EPM on functional outcomes. Surgeons should pay more attention to reducing devascularization during partial nephrectomy.

Sex and Gender Differences in Kidney Cancer: Clinical and Experimental Evidence

Simple Summary

Kidney cancer is a frequent malignant tumor that accounts for approximately 5% of all cancer incidences. It affects both males and females, but males are twice as likely to develop kidney cancer than females. Evidence shows that this discrepancy takes root in individual differences, such as genetics or pathologies that affect the patient. It is then reflected in the clinical characteristics of the tumors, as males have larger and more aggressive tumors. Understanding the sex- and gender-based differences in kidney cancer is essential to be able to offer patients individualized medicine that would better cover their needs in terms of prevention, diagnosis and treatment.

Abstract

Sex and gender disparities have been reported for different types of non-reproductive cancers. Males are two times more likely to develop kidney cancer than females and have a higher death rate. These differences can be explained by looking at genetics and genomics, as well as other risk factors such as hypertension and obesity, lifestyle, and female sex hormones. Examination of the hormonal signaling pathways bring further insights into sex-related differences. Sex and gender-based disparities can be observed at the diagnostic, histological and treatment levels, leading to significant outcome difference. This review summarizes the current knowledge about sex and gender-related differences in the clinical presentation of patients with kidney cancer and the possible biological mechanisms that could explain these observations. Underlying sex-based differences may contribute to the development of sex-specific prognostic and diagnostic tools and the improvement of personalized therapies.

Clinical advantages of robot-assisted partial nephrectomy versus laparoscopic partial nephrectomy in terms of global and split renal functions: A propensity score-matched comparative analysis

OBJECTIVES

To identify predictors of renal function preservation, and to compare the global and split renal function outcomes of robot-assisted partial nephrectomy and laparoscopic partial nephrectomy.

METHODS

Demographic, operative and pathological data, as well as renal function outcomes, of 251 patients who underwent laparoscopic (n = 104) and robot-assisted (n = 147) partial nephrectomy between 2008 and 2018 were retrospectively analyzed. Propensity score matching (1:1) was carried out to adjust for potential baseline confounders. Functional outcomes were assessed based on the estimated glomerular filtration rate and dynamic renal scintigraphy (using ^99m Tc-mercaptoacetyltriglycine), including renal volumetric analysis.

RESULTS

A total of 98 patients were allocated to each partial nephrectomy group. Ischemic (laparoscopic vs robot-assisted partial nephrectomy: 29 vs 15 min, P < 0.001) and operative times (181 vs 100 min, P < 0.001) were shorter in robot-assisted partial nephrectomy. The preservation ratio of global renal function at 3 months (88.3% vs 91.4%, P = 0.040) and 12 months (87.8% vs 91.5%, P = 0.010) postoperatively, and the renal function of the operated kidney (80.3% vs 88.2%, P < 0.001) were greater after robot-assisted partial nephrectomy. In robot-assisted partial nephrectomy, the volume of resected parenchyma was significantly smaller (27.2 vs 15.5 mL, P < 0.001), resulting in greater postoperative normal parenchymal volumes (120 vs 132 mL, P < 0.001) and a greater parenchymal preservation ratio (81.1% vs 90.1%, P < 0.001). The parenchymal preservation ratio was the strongest predictor of renal function preservation after surgery (P < 0.001, odds ratio 6.02).

CONCLUSIONS

Robot-assisted partial nephrectomy allows better preservation of split renal function than laparoscopic partial nephrectomy by increasing the parenchymal preservation ratio. This translates into better postoperative global renal function.

Robotic-assisted Partial Nephrectomy for "Very Small" (<2 cm) Renal Mass: Results of a Multicenter Contemporary Cohort

BACKGROUND

Patient with "very small" (<2 cm) renal mass can be offered active surveillance, thermal ablation, or partial nephrectomy. The management strategy will consider patient preferences and prioritize potential harms associated with each of these options. To date, outcomes of robot-assisted partial nephrectomy (RAPN) in patients with "very small" renal masses have not been reported.

OBJECTIVE

To assess the outcomes of RAPN among patients with "very small" renal masses.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective analysis of a multi-institutional database including RAPN cases performed at eight high-volume US and European centers between 2009 and 2019. Patients were stratified into two groups according to clinical tumor size: <2 cm ("very small" renal mass, study group) and 2-4 cm (control group).

INTERVENTION

RAPN for renal masses.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Baseline characteristics and intraoperative, pathological, and postoperative data were compared between the study and the control group. A "trifecta" was used as surrogate of "surgical quality."

RESULTS AND LIMITATIONS

Overall, a total of 1019 patients were included in the analysis. Of these, 352 had a renal mass of <2 cm (34.5%) and 667 (65.5%) had a renal mass of 2-4 cm. At baseline, the study group presented a lower rate of chronic kidney disease ≥stage III (p < 0.001), a lower RENAL score (p = 0.001), and lower rates of hilar (p = 0.04) and endophytic (p = 0.02) masses. Warm ischemia time was shorter for the study group (median 14 vs 18 min, p < 0.001), which also showed a lower rate of overall postoperative complications (9.6% vs 14.7%, p < 0.001) and no major complications. In terms of oncological outcomes, three and ten patients developed a local recurrence in the study and the control group, respectively (p = 0.1). In the study group, higher estimated glomerular filtration rates were found at discharge (p = 0.001) and at the last follow-up (p = 0.007), which showed a "trifecta" achievement of 90.6%. The retrospective design may limit the generalizability of the findings.

CONCLUSIONS

Whenever an active treatment is indicated or warranted, RAPN represents a minimally invasive management option for "very small" renal masses, as it carries minimal risk of complications and has minimal impact on renal function. While both active surveillance and kidney ablation remain valid management options in these cases, RAPN can be offered and discussed with patients as it provides excellent outcomes with low morbidity.

PATIENT SUMMARY

In this report, we observed that robot-assisted partial nephrectomy represents a true minimally invasive active treatment for "very small" renal masses (<2 cm), as it carries minimal risk of complications and has minimal impact on renal function.

Determinants and Implications of Excised Parenchymal Mass on Robotic-Assisted Partial Nephrectomy Outcomes

OBJECTIVES

To evaluate the association between excised parenchymal mass (EPM) and postoperative renal function (eGFR) following robotic-assisted partial nephrectomy (RAPN). EPM is the amount of healthy renal parenchyma excised during partial nephrectomy in order to achieve safe surgical margins.

METHODS

We evaluated 406 consecutive RAPN performed by a single surgeon to eliminate variations in technique as a factor in EPM. EPM (mL) = (specimen volume * π/6) - (tumor volume * π/6). RENAL score was categorized as easy (4-6), moderate (7-9), or hard (10-12). EPM was grouped into four categories: ≤ 3.9 mL, 4.0-9.9 mL, 10.0-17.7 mL, and >17.7 mL. eGFR was evaluated preoperatively, postoperative day 1 (POD1), 1 month, and 6 months postoperatively.

RESULTS

Median age was 63 years (22-84 years), 252 (62.1%) were male, and median EPM was 9.9 mL (interquartile range 3.9 to 17.7 mL). The median EPM and interquartile range for each RENAL category was 3.7 mL (2.0, 7.9), 12 mL (5.7, 19.4), and 16.2 mL (7.9, 24.3), respectively. Higher EPM was associated with worse changes in eGFR at POD1 (P = 0.005) and 1 month after RAPN (P = 0.002) but was not statistically significant at the 6-month time period (P = 0.35) CONCLUSION: Increased tumor complexity is associated with an increase in EPM during RAPN. Increased EPM is associated with eGFR decline at POD1 and 1 month post RAPN but not at 6 months postoperatively.

The Use of Tissue Adhesive for Tumor Bed Closure during Partial Nephrectomy is Associated with Reduced Devascularized Functional Volume Loss

Objectives

To quantitatively compare the functional renal volume loss, following nephron sparing surgery (NSS) between patients in whom tumor bed closure was done by biological tissue adhesive and those who were managed by standard suture technique.

Methods

From our institutional NSS database we retrospectively collected patients who had two sequential quantitative single-photon emission computed tomography of ^99mTc-dimercaptosuccinic acid uptake studies, the first study immediately before surgery and the second one 3-6 months following surgery. The study group included 69 patients: 26 (37.7%) patients in the sealant group (BioGlue®) and 43 (62.3%) patients in the standard suture group.

Results

No statistically significant differences were noted in the baseline clinical and pathological characteristics of the studied groups. However, there were several statistically significant differences in operative variables: patients in the suture group had larger amount of blood loss (3-fold), longer ischemia time (26.6 vs. 21 minutes,) and slightly longer operation time. Patients in whom tumor bed was closed by sutures had nearly 3-fold higher parenchymal loss compared to patients managed by sealant (26.28 vs. 8.92 ml, p = 0.048).

Conclusions

The use of tissue sealant during tumor bed reconstruction is associated with reduced devascularized parenchymal mass loss and should be considered among modifiable surgical factors during NSS.

Renal volume matters: Assessing the association between excisional volume loss and renal function after partial nephrectomy

BACKGROUND/OBJECTIVES

To investigate the oncological and functional outcomes after partial nephrectomy for clinical stage T1 (cT1) renal cell carcinoma (RCC), and assess the association between excisional volume loss (EVL) and postoperative renal function.

METHODS

We retrospectively reviewed 150 patients with cT1 RCC undergoing partial nephrectomy from 2002 to 2016. End-point evaluation was assessed by recurrence free survival (RFS), overall survival (OS), stage III and stage IV chronic kidney disease (CKD). Regression models were used to determine the risk factors of CKD after surgery. The relationship between EVL and renal function decline was evaluated using Spearman correlation method.

RESULTS

Ninety patients with clinical stage T1a (cT1a) tumors and 60 patients with clinical stage T1b (cT1b) tumors were included. There were no differences in RFS, OS, and risk of stage III and stage IV CKD between the two groups. In Cox regression models, multivariate analysis showed that preoperative estimated glomerular filtration rate (eGFR) was an independent risk factor for developing stage III (hazard ratio 0.937, P < 0.001) and stage IV CKD (hazard ratio 0.929, P = 0.027). EVL was significantly associated with postoperative eGFR decrease. (Correlation Coefficient = 0.325, P = 0.003).

CONCLUSIONS

Patients with cT1a and cT1b RCC have comparable oncological and functional outcome after partial nephrectomy, and preoperative eGFR is an independent factor to predict developing CKD. EVL has influence on the postoperative renal function decline.

Gender-specific risk factors for renal cell carcinoma: a systematic review

PURPOSE OF REVIEW

The relationship between gender and kidney cancer incidence/outcomes has been largely evaluated and may significantly impact the management of patients diagnosed with these tumors. We reviewed and summarized the most relevant recent publications reporting about this clinically meaningful relationship.

RECENT FINDINGS

The incidence of kidney cancer is higher in men than in women. Male gender is clearly associated with more aggressive histological characteristics both in terms of tumor stage and grade. Similarly, male gender has been found to be associated with worse perioperative and oncological outcomes. Several genetic and molecular markers that may partly explain these observed differences have been evaluated. However, the impact of these markers on clinical practice has not been clearly demonstrated.

SUMMARY

Gender is significantly associated with kidney cancer incidence, characteristics and outcomes. Future efforts are still needed to explore the biological and molecular basis underlying of this relationship.

"At-risk" kidney: How surgical factors influence renal functional preservation after partial nephrectomy

OBJECTIVES

To investigate the influence of surgical modifiable factors on chronic kidney disease upstaging in a contemporary cohort of patients with normal and "at-risk" kidneys undergoing partial nephrectomy.

METHODS

We reviewed 778 consecutive patients with (n = 634)/without (n = 144) chronic kidney disease or risk factors for chronic kidney disease in our institutional partial nephrectomy database. Chronic kidney disease upstaging was assessed using glomerular filtration rate measurements preoperatively and at 3-12 months postoperatively. Using a multivariate logistic regression, baseline clinicodemographic factors, and the operative measurements of excisional volume loss and warm and cold ischemia time on rates of chronic kidney disease upstaging were determined. Marginal effects were used to analyze the impact of ischemia time and generate interaction curves.

RESULTS

Chronic kidney disease/risk factors for chronic kidney disease had equivalent rates of chronic kidney disease upstaging as the healthy kidney cohort (31.5% vs 38.2%, P = 0.15). Of the entire cohort, 2.8% were upstaged to stage IV-V chronic kidney disease. Multivariate analysis found a significant association between chronic kidney disease upstaging and excisional volume loss in both cohorts (no chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.63, P = 0.04; chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.42, P = 0.001). Only in the chronic kidney disease/risk factors for chronic kidney disease cohort, there was an association between ischemia type/duration and chronic kidney disease upstaging (odds ratio 1.04, P = 0.04). Warm ischemia began to predict an increased risk of chronic kidney disease upstaging at 17.6 min, which became statistically significant at 49 min.

CONCLUSIONS

Chronic kidney disease upstaging is common after partial nephrectomy. Although volume loss unequivocally affects rates of upstaging irrespective of baseline renal function, warm ischemia time disproportionately influences "at-risk" kidneys. Therefore, strong consideration should be given to minimizing volume loss and using cold ischemia when extended clamp times are anticipated in "at-risk" kidneys.

Organ-sparing procedures in GU cancer: part 1-organ-sparing procedures in renal and adrenal tumors: a systematic review

PURPOSE

Organ-sparing surgery (OSS) for the kidney and adrenals has emerged as the need for preservation of function is paramount in patients with poor functional reserve. As reports increasingly showed that oncological outcomes were equivalent to radical excision, elective OSS became a viable alternative in patients with otherwise normal reserve. In this review, we summarize the current knowledge of OSS for adrenal and renal tumors.

MATERIALS AND METHODS

PubMed, Web of Science and Cochrane Library Central Search were searched for recently published articles up to December 2017. The following keywords were used; "partial adrenalectomy", "adrenal sparing", "partial nephrectomy", "nephron sparing", "kidney/renal cancer".

RESULTS

Partial adrenalectomy became an attractive alternative to total adrenalectomy avoiding adrenal insufficiency. Both minimally invasive surgery and ablative techniques were increasingly reported for adrenal OSS with adequate residual adrenal function and excellent oncological outcome. Radical nephrectomy remained for many years as the gold standard of treatment for organ-confined renal cell carcinoma. As the need to reduce the impact on renal function, more conservative approaches were utilized. Soon, the non-inferiority of nephron-sparing surgery to that of radical excision became evident and elective partial nephrectomy was gaining ground as the standard of care for small renal masses in patients with normal contralateral kidneys.

CONCLUSIONS

Herein, we present a comprehensive review of the current status of OSS in renal and adrenal tumors.

The correlation between affected renal function and affected renal residual volume: A retrospective outcome of laparoscopic nephron-sparing partial nephrectomy with segmental renal artery blocking-up for localized renal tumors

Laparoscopic nephron-sparing partial nephrectomy with segmental renal artery blocking (SRPN) has been widely used in the treatment of localized renal tumors. However, the impact of ischemia-reperfusion injury (IRI) during SRPN remains controversial. This study aims to evaluate the correlation between affected renal function and affected renal volume after SRPN for localized renal tumor treatment, explore the effect of IRI on renal function after SRPN.A total of 39 patients who underwent SRPN for localized renal tumor from June 2009 to April 2012 were reviewed. These patients were followed-up for 5 years. The preoperative affected renal glomerular filtration rate (aGFRpre), postoperative affected renal glomerular filtration rate (aGFRpost), preoperative affected renal volume (aVolpre), and postoperative affected renal volume (aVolpost) were collected during the follow-up period. The correlation between aGFRpost/aGFRpre and aVolpost/aVolpre was compared.A total of 33 patients were successfully followed up. After 3, 6, 12, 24, and 60 months, aGFRpost was 34.6 ± 4.6, 34.7 ± 4.8, 34.9 ± 4.4, 35.1 ± 4.4, and 35.2 ± 4.2 mL/min. The correlation coefficients between aGFRpost/aGFRpre and aVolpost/aVolpre were 0.659 (P = .000), 0.667 (P = .000), 0.663 (P = .000), 0.629 (P = .000), and 0.604 (P = .000), respectively. The limitation of this study was the small cohort size.For the localized renal tumor, aGFRpost was associated with aVolpost, but was not associated with intraoperative factors, such as the time of clamping of the affected segmental renal artery. As a part of nephrons, the resected tumor tissue caused the lack of inherent nephrons, resulting in the loss of renal function. More nephrons should be maintained before resecting the tumor completely during SRPN.Trial registration: ChiCTR-RRC-17011418.

Systematic Review and Pooled Analysis of the Impact of Renorrhaphy Techniques on Renal Functional Outcome After Partial Nephrectomy

Despite the important relationship between renorrhaphy and functional outcomes of partial nephrectomy, the urological guidelines do not provide recommendations about the optimal renorrhaphy technique. We carried out the first pooled literature analysis of the impact of suture technique on ultimate renal function after partial nephrectomy. Three studies comparing interrupted versus running suture including data on glomerular filtration rate (GFR) were included, for a total of 124 versus 269 patients. No significant differences were found between pre- and postoperative GFR in either patients who received an interrupted suture (weighted mean difference, -4.88ml/min, 95% confidence interval [CI] -11.38; 1.63, p=0.14) or those who received a running suture (-3.42ml/min, 95% CI -9.96; 3.12, p=0.31). Three studies comparing single- versus double-layer renorrhaphy included data on GFR (321 vs 199 patients). A benefit in functional outcomes favored single-layer technique (-3.19ml/min, 95% CI -8.09; 1.70, p=0.2 vs -6.07ml/min, 95% CI -10.75; -1.39, p=0.01). In conclusion, our quantitative synthesis suggests a renal functional benefit of the single-layer closure during partial nephrectomy. PATIENT SUMMARY: The available studies on renal functional data included in the present review suggest that "less is more" for renorrhaphy after partial nephrectomy. The single-layer renorrhaphy technique showed advantages in renal functional outcomes compared with the double-layer technique.

Influence of symptomatic pseudoaneurysms on postoperative renal function after partial nephrectomy: results of a matched pair analysis

PURPOSE

A symptomatic pseudoaneurysm (SPA) is a rare but severe complication after partial nephrectomy (PN). Selective trans-arterial embolization (TAE) is the treatment of choice with high success rates. However, the influence of this intervention on postsurgical renal function has not been studied.

METHODS

Between 2005 and 2016 we performed 1047 PNs at our institution. Postsurgical SPA occurred in 40 patients (3.8%). Patients with and without SPA were matched in a 1:2 ratio concerning tumor complexity (RENAL) and pre-operative renal function (CKD stage). Any CKD upstage and a relevant CKD progression (CKD ≥ III) were defined as endpoints. Furthermore, the influence of the amount of contrast agent applied during TAE was assessed.

RESULTS

All patients with SPA were treated successfully with TAE. No significant difference could be detected concerning clinical, functional and surgical aspects. Median follow-up time accounted for 12.5 (6.75-27.5) months. Kaplan-Meier analyses detected an increased rate of any CKD upstage (p = 0.066) and relevant CKD progression (p = 0.01) in patients with SPA. Multivariate analysis identified post-operative SPA to be an independent predictor for a relevant CKD progression (HR 4.15, p = 0.01). The amount of contrast agents used did not have an impact on the development of a relevant CKD progression (p = 0.72).

CONCLUSION

Patients treated with TAE after PN show an additional risk for an impairment of renal function over time. Hence, those patients should explicitly be informed about possible consequences and closely monitored by nephrologists.

A Nomogram to Predict Significant Estimated Glomerular Filtration Rate Reduction After Robotic Partial Nephrectomy

BACKGROUND

Decreased functional outcome after partial nephrectomy is associated with overall mortality.

OBJECTIVE

To create a model that predicts ≥25% reduction from baseline estimated glomerular filtration rate (eGFR) in patients undergoing robot-assisted partial nephrectomy (RAPN) and to investigate the role of acute kidney injury (AKI) in this patient population.

DESIGN, SETTING, AND PARTICIPANTS

A total of 999 patients were identified from a multi-institutional database. Renal function was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for chronic kidney disease (CKD). AKI was defined as >25% reduction in eGFR from pre-RAPN period to discharge.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A nomogram to predict significant eGFR reduction (≥25% from baseline) in the time-frame between 3 and 15mo after RAPN was built based on the coefficients of Cox survival function that ultimately included age, sex, Charlson comorbidity index, baseline eGFR, RENAL nephrometry score, AKI in patients with normal baseline renal function, and AKI on CKD. Such landmark analysis was chosen in order to account for eGFR fluctuations occurring within the first 3mo of RAPN. The proportional hazard assumption was evaluated through the Schönfeld test. Internal validation was performed using the leave-one-out cross validation. Calibration was graphically investigated. The decision curve analysis (DCA) was used to evaluate the net clinical benefit.

RESULTS AND LIMITATIONS

Median (interquartile range [IQR]) age at surgery was 61yr (51, 68). Overall, 146 patients experienced significant eGFR reduction; median follow-up for survivors was 12.4mo. The 15-mo probability of significant eGFR reduction was 19%. All variables fitted into the model, including AKI in patients with normal renal function (hazard ratio [HR]: 4.51; 95% confidence interval [CI]: 3.12, 6.60; p<0.001) and AKI on CKD (HR: 4.90; 95% CI: 2.17, 11.1; p<0.001), emerged as predictors of significant eGFR reduction (all p≤0.048) and were considered to build a nomogram. The internally validated c index was 73%. The model demonstrated excellent calibration and a net benefit at the DCA with probabilities ≥4%.

CONCLUSIONS

We developed a nomogram that accurately predicts significant eGFR reduction after RAPN. This model may serve as a tool for early identification of patients at high risk for significant renal function decline after surgery.

PATIENT SUMMARY

We have developed a model for the prediction of renal function loss after partial nephrectomy for renal cancer.

Development and Internal Validation of a Nomogram for Predicting Renal Function after Partial Nephrectomy

Loss of renal function can be a clinically impactful event after partial nephrectomy (PN). We aimed to create a model to predict loss of renal function in patients undergoing PN. Data for 1897 consecutive patients who underwent PN with warm ischemia between 2008 and 2017 were extracted from our institutional database. Loss of renal function was defined as upstaging of chronic kidney disease in terms of the estimated glomerular filtration rate (eGFR) at 3 mo after PN. A nomogram was built based on a multivariable model comprising age, sex, body mass index, baseline eGFR, RENAL score, and ischemia time. Interval validation and calibration were performed using data from 676 patients for whom complete data were available. Receiver operator characteristic (ROC) curves with 1000 bootstrap replications were plotted, as well as the observed incidence versus the nomogram-predicted probability. We also applied the extreme training versus test procedure known as leave-one-out cross-validation. After internal validation, the area under the ROC curve was 76%. The model demonstrated excellent calibration. At an upstaging cutoff of 27% probability, upstaging was predicted with a positive predictive value of 86%. PATIENT SUMMARY: In this report, we created a model to predict postoperative loss of renal function after partial nephrectomy for renal tumors. Inputting baseline characteristics and ischemia time into our model allows early identification of patients at higher risk of renal function decline after partial nephrectomy with good predictive power.

Infrared Light Structured Sensor Three-dimensional Approach to Estimate Kidney Volume: A Validation Study

OBJECTIVE

To validate a new procedure for the three-dimensional estimation of total renal parenchyma volumeusing a structured-light infrared laser sensor.

METHODS

To evaluate the accuracy of the sensor for assessing renal volume, we performed 3 experiments. Twenty freshly excised porcine kidneys were obtained. Experiment A, the water displacement method was used to obtain a determination of the renal parenchyma volume after immersing every kidney into 0.9% saline. Thereafter a structured sensor (Occipital, San Francisco, CA) was used to scan the kidney. Kidney sample surface was presented initially as a mesh and then imported into MeshLab (Visual Computing Lab, Pisa, Italy) software to obtain the surface volume. Experiment B, a partial excision of the kidney with measurement of the excised volume and remnant was performed. Experiment C, a renorrhaphy of the remnant kidney was performed then measured. Bias and limits of agreement (LOA) were determined using the Bland-Altman method. Reliability was assessed using the intraclass correlation coefficient (ICC).

RESULTS

Experiment A, the sensor bias was -1.95mL (LOA: -19.5 to 15.59, R² = 0.410) with slightly overestimating the volumes. Experiment B, remnant kidney after partial excision and excised kidneyvolume were measured showing a sensor bias of -0.5mL (LOA -5.34 to 4.20, R²= 0.490) and -0.6mL (LOA: -1.97.08 to 0.77, R² = 0.561), respectively. Experiment C, the sensor bias was -0.89mL (LOA -12.9 to 11.1, R²= 0.888). ICC was 0.9998.

CONCLUSION

The sensor is a reliable method for assessing total renal volume with high levels of accuracy.

Are there limits of robotic partial nephrectomy? TRIFECTA outcomes of open and robotic partial nephrectomy for completely endophytic renal tumors

BACKGROUND

To compare the outcomes of robot-assisted (RAPN) and open partial nephrectomy (OPN) for completely endophytic renal tumors.

METHODS

Consecutive patients undergoing OPN or RAPN for entirely endophytic tumors in four high-volume centers between 2008 and 2016 were identified. Endophytic masses were identified based on sectional imaging. Patient characteristics and surgical outcome were compared using Mann-Whitney-U-test and chi-squared-tests. Uni- and multivariate analyses were performed to identify predictors of TRIFECTA achievement and excisional volume loss.

RESULTS

Out of 1128 patients, 10.9% (64) of RAPN and 13.9% (76) of OPN underwent surgery for entirely endophytic tumors. Operative time was longer for RAPN (169 vs 140 min, P = 0.03) while ischemia time was shorter (13 vs 18 min, P = 0.001). Complication rates were comparable (21% OPN vs 22% RAPN, P = 0.91) and TRIFECTA achievement was not different between the groups (68% OPN vs 75% RAPN, P = 0.39). In multivariate analyses type of surgery was not associated with TRIFECTA achievement or excisional volume loss. Here, only tumor complexity (OR 0.48, P = 0.001) and size (OR 1.01, P = 0.002) were independent predictors.

CONCLUSION

For entirely endophytic tumors, both RAPN and OPN offer good TRIFECTA achievement. This encourages the use of NSS even for these highly complex tumors using the surgeon's preferred approach.

Volume and Shape Assessment of Renal Radiofrequency Ablation Lesion

OBJECTIVE

To evaluate the microscopic characteristics and quantify the volume of a radiofrequency ablation (RFA) lesion.

METHODS

Ten male pigs were submitted to laparoscopic RFA. An RFA needle was introduced in the lower pole of the left kidney to create a lesion expected to be a sphere of 2.0 cm diameter. The animals were followed up for 21 days. Kidneys were weighed and the volume was assessed using Scherle's method. Cavalieri's principle was used to assess the RFA volume, and sphericity was calculated to assess RFA lesion. One sample t test was used to compare RFA volume with the volume of a sphere of 2.0 cm diameter, and sphericity to hypothetical values of a sphere and an icosahedron. Fragments of RFA region were histologically evaluated.

RESULTS

Three animals developed postoperative complications and were excluded from the analyses. There was no difference in the mean weight and volume between right and left kidneys following RFA. The mean total volume of RFA injury was 3.44 cm³. There was no difference in the RFA volume in comparison with hypothetical volumes of a sphere and an icosahedron of 2.0 cm diameter. Sphericity of the RFA injury was not similar with a sphere; however, it was similar to an icosahedron. Histology revealed areas of coagulation necrosis, fibrosis, and inflammatory mononuclear infiltration. Areas with normal tissue were also observed.

CONCLUSION

The volume of injury caused by RFA was as expected and its shape was comparable with an icosahedron. Microscopic evaluation revealed areas of normal-appearing tissue.

Laparoscopic ultrasonography: The wave of the future in renal cell carcinoma?

Laparoscopic or robotic surgery is the main method of treating renal cell carcinoma (RCC). Laparoscopic surgery can accurately target lesions and shorten patient recovery time. Renal endogenous tumors or inferior vena cava tumor thrombi are very difficult to remove using the laparoscopic approach. The emergence of laparoscopic ultrasonography (LUS) has solved this problem. LUS can assist in the detection of tumor boundaries and the extent of tumor thrombi. The lack of tactile feedback may hinder the development of laparoscopic surgery for the treatment of renal cancer. LUS has become an important tool that has improved the rates of successful surgery. LUS is applied in not only early and locally advanced RCC treatment but also in monitoring ablation therapy, testing renal blood perfusion, and exposing renal pedicles. Sonographic techniques used for LUS include initial B-mode, Doppler, and contrast-enhanced ultrasound (CEUS). Contrast agents applied for CEUS do not induce nephrotoxicity and can display renal perfusion more accurately than the regular color Doppler ultrasound. According to current literature, LUS is a promising technique for the treatment of RCC, especially for endogenous RCC or RCC with thrombosis, and for monitoring the effectiveness of radiofrequency ablation, although further well-designed studies are warranted.